ICP
late signs of increased ICP
cushings triad
coma
posturing
brain herniation
fixed dilated pupils
Early signs of SAH
THUNDERCLAP headache
double vision
neck pain, stiffness
altered LOC
n/v
name the types of fluids in fluid resuscitation
colloids
crystalloids
blood products
name the two types of SCI
incomplete
complete
Which meningitis is considered aseptic
viral
3 mild TBI manifestations
Loss of consciousness for seconds to minutes
headache
confusion
blurred vision
tinnitus
photophobia
n/v
tiredness
CHANGE IN LOC
sluggish pupils/papilledeman/v
headache
seizures
Late signs of SAH
Vasospasm/rebleeding
cerebral ischemia
coma
seizures
hydrocephalus
primary assessment in client's who have sustained a trauma
AIRWAY
first intervention when autonomic dysreflexia is suspected
sit the patient up 90 degrees and dangle the legs
Bacterial meningitis precautions
droplet
priority intervention if client CPP is <60
notify the provider
What should we keep PaCO2 levels at for a patient with increased ICP?
35 or less
Manifestations of brain death
loss of brainstem reflexes
no resp effort
no reflexes
biggest risk with fracture traumas
describe neurogenic shock
hypotension
bradycardia
poikilothermic
describe the CSF in bacterial meningitis
cloudy
WBC abundant
glucose low
protein high
Contraindicated nursing skill in basilar skull fracture patients
NG/OG tube placement
if suspected increased ICP, LP is contraindicated
Priority nursing assessment for a client with new LOC, increasing ICP, or neurological change
pupillary assessment
antifibrinolytic
antihypertensives
calcium channel blocker nimotop
anticonvulsants
antipyretics
manage hypotension if needed
describe beck's triad
tachycardia
hypotension
muffled heart sounds
describe spinal shock
flaccidity
hypotension
bradycardia
absent reflexes
paralyzed below level of injury
Nursing management for meningitis
monitor for ICP fluctuations
administer anticonvulsants, antipyretics, antivirals or antibiotics
Loss of consciousness for minutes to hours
seizure
dilated pupils/loss of vision
balance issues
weakness
aggression
depression
difficulty communicating
sensory perception changes
Describe Cushing's triad
Bradycardia
Widened pulse pressure
cheyne-stokes respirations
calculate the CPP
90/44
ICP 3
round to the nearest whole number
56
client assessment data indicating good or bad perfusion
URINE OUTPUT
ways to prevent autonomic dysreflexia
empty bladder entirely
bowel regimen
fluids and fiber
range of motion
turn Q2 hours
describe kernigs and brudzinskis signs
Brudzinski sign is when neck flexion causes the individual to flex their hips and knees automatically. Kernig sign, a leg is unable to be extended with the knee flexed to a 90-degree angle.
3 nursing evaluation of neurological status in patients with TBI
LOC
following commands
motor response to stimuli
GCS
monitor for asymmetries
monitor for posturing
Provide four nursing interventions to decrease ICP
dim lights
limit noise
don't cluster large activities of care together
HOB 30
limit suctioning
administer osmotic diuretic or 3% saline
3 risk factors for SAH
untreated HTN
smoking
etoh
illicit drug use
greater than 40
3 bnursing interventions for client's who have sustained trauma are are now in the ICU
monitor VS
ABG
hemodynamics
pain control
monitor for bleeding
causes of autonomic dysreflexia
bladder distension
uti
coccyx pressure injury
fecal impaction
2 nursing interventions after LP
have client lay flat for 2 hours
monitor vital signs
assess for bleeding
monitor for spinal headache
periorbital ecchymosis
rhinorrhea
otorrhea