ICP
What are examples of changes in level of consciousness?
What is falling asleep in the middle of sentences, difficulty to arouse, lethargy?
What does the care plan for a person experiencing migraines look like?
What is quiet, dark room, medications that include caffeine (example: Sumatriptan/Imitrex) over basic Tylenol or NSAID, headache diary?
A patient with AD who is a fall risk at a nursing facility should have their room where for safety?
What is close to the nurses station?
What is decerebrate posturing and what injury is it associated with?
What is extension of the limbs with internal rotation of shoulder and wrists? What is brainstem injury?
When a patient is receiving a CT scan- what is the nurse's role?
What is check renal function, explain warm sensation at groin area, inquire about shellfish/iodine allergies, monitor for allergic reaction?
What are manifestations of bacterial meningitis?
What is nuchal rigidity, high fevers, severe headache, photophobia, petechiae rash on chest/extremities, positive Kernig's sign, positive Brudzinski sign?
What does paraplegia mean?
What is the inability to feel or move lower extremities?
What osmotic diuretic is used to treat cerebral edema?
What is mannitol?
What are interventions used to decrease intracranial pressure?
What is avoid hip flexion (knee gatching), HOB at least 30 degrees, administer stool softeners/ antitussives/ antiemetics, quiet dark room?
A patient is experiencing autonomic dysreflexia. What should the nurse do while awaiting doctor's orders?
What is Place the patient in bed- RAISE the head of the bed, check BP every 5 minutes, check urinary tubing for kinking and placement, check rectal vault for impacted stool, remove TED stocking, inspect the skin?
What is a positive Brudzinski sign? What does it indicate?
What is when a patient's neck is flexed- their hips and knees flex? What is meningitis?
What other symptoms would be present?
What are triggers for seizures?
What are excessive alcohol, substance withdrawal, flashing lights, hyperthermia, extreme fatigue, over caffeinated?
Provide Dexamethasone (Decadron) patient education.
What is given to reduce cerebral edema, may cause hyperglycemia, may cause patient to retain fluid, may cause weight gain, immunosuppression?
What happens to the body when a person has a sympathetic nervous system response?
What is increased heart rate, decrease in peristalsis, dilation of bronchioles, gooseflesh, sweating, and increased blood pressure?
What are normal changes in the central nervous system associated with aging?
What are reduced blood flow to the brain, impaired short term memory, decreases in acetylcholine, sleep disturbances?
What are nursing interventions for a patient with bacterial meningitis?
What is ISOLATE patient, administer antibiotics, quiet dark room, implement precautions for both seizures and increased ICP?
Describe a generalized seizure. What should the nurse do in response to a patient having a generalized seizure?
What is bilateral jerking of extremities- possible incontinence or emesis? What is move furniture out of the way, place patient on left side, place pillow under head, loosen tight clothing, time the event?
Provide donepezil (Aricept) patient education.
What is syncope (fainting) episodes may occur, bradycardia, administer at bedtime to avoid daytime sedation, and monitor for diarrhea?
What are manifestations of increased ICP?
What is dilated pupil (fixed/sluggish) on side of brain, change in LOC, arterial hypertension (increasing systolic blood pressure), bradycardia, irregular respirations headache, rising temperature?
A mental status exam (MSE) performed for a patient that is suspected of having dementia involves what test?
What is ability to perform calculations, LOC, presence of suicidal thoughts, level of orientation?
What is the nurse's role when a patient is receiving a lumbar puncture?
What is provide oral fluids, Neurovascular exam (toes), monitor for pain and nausea, neurologic exams, maintain bedrest (supine for 4-8 hours)?
How can skin breakdown be prevented in patients that have plegia?
What is elevate heels off bed with a pillow, moisture skin, turn and reposition, frequent incontinence care, increased protein nutrition?
Provide pramipexole (Mirapex) patient education.
What is instruct the patient that sleep attacks may occur, do noy drive, take with food to reduce nausea?