Increased ICP
The nurse caring for a patient with increased ICP implements the following interventions: Decreases the number of visitors, speaks calmly, and creates a quiet environment. The nurse includes these measures in the plan of care to achieve this.
What is reduced stimuli?
This type of injury involves a total loss of all sensory and motor function below the level of the injury.
What is a complete spinal cord injury?
If Battle's sign, raccoon eyes, and this clinical manifestation are present, the patient may have a basilar skull fracture and requires additional assessment.
What is clear fluid that leaks from the patient’s nose or ears?
*Any clear fluid that leaks from the patient’s nose or ears should be assessed for CSF.
This assessment tool is used to determine the severity of a stroke.
What is the NIHSS?
This type of injury occurs when the brain strikes the same side of the skull as the side of impact.
What is a coup injury?
Bradycardia, irregular respirations and hypertension with a wide pulse pressure are considered this.
What are late signs of ICP? What is Cushing's triad?
Painful stimuli like fecal impaction, a kinked urinary catheter, or constrictive clothing can cause this condition in a patient with a spinal cord injury.
What is autonomic dysreflexia?
Any skull fracture would be considered this type of brain injury.
What is a primary brain injury?
After a stroke, patients often have this condition which puts them at risk for aspiration.
What is dysphagia?
This type of injury occurs when the brain strikes the opposite side of the skull as the side of impact.
What is a contrecoup injury?
Continuous ICP monitoring is indicated when ICP reaches this level.
What is > 20 mm/Hg?
This syndrome has the best prognosis of all the incomplete spinal cord syndromes.
What is the Brown-Sequard syndrome?
This type of brain injury includes any altered process in brain function due to an initial injury that worsens the patient outcomes.
What is a secondary brain injury?
This diagnostic test is done to determine if a patient has had an ischemic stroke or a hemmorhagic stroke.
What is a CT scan?
The body is able to maintain cerebral perfusion through this mechanism.
What is autoregulation?
According to this theory, the total volume within the fixed cranial space is constant. If brain tissue swells, CSF volume must decrease to compensate and prevent ICP from rising further.
What is the Monroe-Kellie hypothesis?
This may occur immediately after a spinal injury and can last from several hours to several weeks.
What is spinal shock?
Loss of consciousness for 24 or more hours or amnesia for more than 7 days is associated with this condition.
What is severe TBI?
When the cerebral blood flow is interrupted, glucose, glycogen, and ATP are depleted and the sodium-potassium pump fails, leading to cellular and vascular swelling, which further decreases blood flow. This occurs in this short amount of time.
What is as little as 4 to 5 minutes?
These 4 clinical manifestations indicate increasing ICP.
What is restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern?
These 4 interventions are appropriate when caring for a patient with increased ICP.
What is elevating the head of the bed, administering osmotic diuretics, providing sedation and paralysis, and performing frequent neurologic assessments?
According to the guidelines for emergency care, if a spinal injury is suspected, these actions are crucial to prevent further damage.
What are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring the client from the stretcher to the hospital bed with backboard in place?
These clinical manifestations are associated with a moderate to severe traumatic brain injury. (Name 3)
What is prolonged unconsciousness, bleeding in the brain, difficulty breathing?
A client has an ischemic stroke and their systolic blood pressure remains > 185 mm/Hg and diastolic blood pressure remains > 110 mm/Hg after treatment. Based on this information the nurse knows this about the client's treatment plan.
What is exclusion criteria for thrombolytic therapy?
*A systolic blood pressure that remains > 185 mm/Hg and diastolic blood pressure that remains > 110 mm/Hg after treatment excludes a client who has had an ischemic stroke from eligibilty to receive tPA/ thrombolytic therapy.
A decreasing level of consciousness and unequal pupils are critical signs of this.
What is increased ICP and possible cerebral edema or ischemia?