TBI
After a head injury, what time frame should you be checking the patient and noting a TBI?
The first 24 hours.
What kind of blood pressure could we expect with a patient that has a spinal cord injury?
Hypotensive
For IICP would the symptoms be opposite or the same as shock?
Opposite
The RN administers an enema to a patient with fecal impaction from AD, how long should she wait afterwards before beginning digital stimulation?
10-15 minutes
What is the GCS measuring?
LOC- Level of Consciousness
What type of precautions should you place your TBI patient on?
Seizure precautions.
If a patient is in neurogenic shock what would their fluid status look like?
Hypovolemic. *Key Word SHOCK, coma, death.
What is the normal range of ICP?
5-15 mmHg.
Which position would you assist your patient into, to induce orthostatic hypotension?
Sitting Position
What patient diagnoses/condition would we want to use the GCS on?
Spinal cord injury or TBI
What it the NUMBER ONE nursing intervention for a TBI?
Stabilize the cervical spine and immobilize!
What maneuver method would be used to reposition a patient with a spinal cord injury?
Log Roll
What is the Drug and Class of medication used for IICP?
Mannitol- Diuretic
Is vasoconstriction above or below the level of injury in an AD patient?
Below- cool, pale, no sweating.
What are the (3) responses being measured with the GCS?
Eye opening response, Best verbal response, Best motor response.
When assessing the patient name TWO types of fluid that you may notice as a S/S of an active TBI.
Which one of these medications would we likely use for a SCI patient? Lorazepam or Albuterol?
Lorazepam- Sedating, calming, anxiety, anticonvulsant effects.
What is the outcome of increased intracranial pressure?
Impaired perfusion. If pressure builds up, it can put pressure on the vessels and prevent perfusion from occurring.
Why would a patient with AD have an indwelling urinary catheter or suprapubic catheter in place?
Urinary retention
What is the best score the patient can receive on the GCS?
15
Which extremity would be effected in a patient with TBI?
Loss of sensation to any extremity can be found.
Where would you find paralysis on a patient with a spinal cord injury?
BELOW the level of injury. ^Above C-4
Which part of the brain controls things such as breathing and blood pressure?
The Brain Stem: Breathing, blood pressure, heartbeat, swallowing (If the brain stem is damaged, prognosis is very low)
Out of these medication classes, which would you NOT need for treatment of manifestations of AD? (3 for, 3 not). Benzodiazepine, PPI, vasodilator, stool softener, calcium channel blocker, mucolytic.
PPI, CCB, Mucolytic
A score of which number would indicate the patient is in a coma or severe head injury?
Between 3-8