IICP, Surgeries & Trauma
Normal intracranial pressure (ICP).
What is 10-20 mmHg (mercury)?
SIADH
Name nursing interventions.
What is Syndrome of Inappropriate Antidiuretic Hormone secretion?
What are closely monitoring I&O, daily weight, urine and blood results, and frequent neuro assessments?
The drugs pyridostigmine (Mestinon), an anticholinesterase, and prednisone and azathioprine, immunomodulators are given to this population. Name the neurological disorder these medications are used for.
What is Myasthenia Gravis?
The part of the brain that controls coordination/balance, proprioception, and posture.
What is the cerebellum?
Name at least 3 diagnostic tests performed in patients with altered motor/sensory function.
What are CT scan, PET scan, MRI, lumbar puncture, and or EMG?
Name at least 5 clinical manifestations of ICP.
What is a change of level of consciousness (LOC), restlessness, confusion, agitation, increased drowsiness, seizure activity, pupillary changes, headache, vomiting, blurred vision, papilledema, widening pulse pressure, nuchal rigidity, vital sign changes, and in an infant, bulging fontanels or increased head circumference?
List the four nursing interventions/priorities for a patient after cranial surgery.
What are maintaining an adequate airway, assessing LOC, manage fluid & electrolytes, observe motor function, nutrition, skin, and complications?
Your patient has Multiple Sclerosis. Name at least five nursing interventions/priorities.
What are manage pain, administer medications as prescribed, decrease fatigue (provide frequent rest periods), encourage ROM exercises, check gag reflex, maintain suction at the bedside, encourage high fiber diet, teach bowel and bladder training, teach self-care to the best of the patient's ability, encourage verbalization of concerns, sexual concerns, provide emotional support, and refer to support groups?
Name at least two focused nursing assessments for a patient with altered motor/sensory function.
What are physical (for trauma, surgery, pressure), physiological (for Parkinson's, CVA, MS, Myasthenia Gravis, ALS, Guillian Barre), microbiological (viral, bacterial), and psychosociocultural (nutrition, alcohol/substance use)?
Name at least five nursing interventions for a patient with altered motor/sensory function.
What are maintain airway, provide safety, maintain fluid balance, maintain adequate nutrition, provide mouth care, maintain skin and joint integrity, provide patient/family teaching, prevent potential complications, provide emotional support, and or refer to home care?
Define differences between decorticate rigidity and decerebrate rigidity.
For decorticate rigidity, what is an abnormal posturing where the person is stiff with bent arms, clenched fists with wrists and fingers bent and held on the chest, and legs held out straight?
For decerebrate rigidity, what is an abnormal body posture characterized by a person being stiff, with arms and legs held straight out, toes pointed downward, and the head and neck arched backwards?
A patient who has a SCI state he needs to sit up for 15-20 mins before transferring to the wheelchair. The nurse knows this to avoid__________
What is postural hypotension?
List at least 4 common clinical manifestations in a patient with altered motor/sensory function.
What are pain, seizures, dizziness/vertigo, visual disturbances, weakness, and or abnormal sensation?
Define Expressive Aphasia.
What is the client who can understand the spoken word, but cannot speak it?
Name two types of CVA (stroke).
What are ischemic and hemorrhagic?
Name at least 5 nursing interventions for a patient with increased intracranial pressure (IICP).
What are the frequent monitoring of respiratory status and lung sounds to maintain a patent airway, no coughing, maintain the head in neutral position with the head of bed at 15-30°, maintain O2 (to reduce metabolic demands), change position carefully, provide stool softener (to prevent straining with BM), maintain a calm, quiet environment, monitor fluid status with hourly I&O in the acute phase, and strict aseptic technique when managing the ICP monitoring system?
Name at least 4 clinical manifestations in an infant with hydrocephaly.
What are increased head circumference, bulging fontanels, irritability, high-pitched cry, vomiting/poor feeding, spasticity, dilated scalp veins, sunset eyes, opisthotonus dorsal arch position, and thin skull?
The medications glutamate antagonist (Rilutek), baclofen (Lioresal), dantrolene sodium (Dantrium), and diazepam (Valium) are given for this condition.
What is Amyotrophic Lateral Sclerosis (ALS)?
Bonus - aka (hint-a famous baseball player)
The three areas of scoring on the Glasgow coma scale.
What are eye-opening, verbal response, and motor response?
BE FAST
What is: Balance Eyes Face (drooping) Arm (weakness) Speech (difficulty) Time to Call 911?
A patient has a severe head injury, and they start showing signs of ICP with decorticate posturing. The nurse correctly identifies the patient's posture because it looks like this.
What are flexed upper extremities towards the chest with plantar-flexed lower extremities?
Name at least five nursing interventions/priorities for a patient with meningitis.
What are placing on respiratory isolation, antibiotic administration, pain management, corticosteroid administration (dexamethasone), anticonvulsants (if ordered), dark, quiet environment, treat hyperthermia such as antipyretics and or cooling blankets, encourage hydration, frequent vital signs and neuro assessments, and monitor for SIADH?
Name other disciplines that play a role in the rehabilitation of patients with a neuro-degenerative disease.
What are Physical Therapy, Occupational Therapy, Speech (or swallow) Therapy, Cognitive Rehabilitation, and Vocational Rehabilitation?
The nurse knows that following symptoms of an ischemic stroke you only have _______hours to administer t-PA (a tissue plasminogen activator).
What is 3 hours?
Impaired speech and language, slow performance, visual field deficits, aware of deficits leading to depression are signs of which side of the brain is affected in the presence of a CVA.
What is the left side of the brain?