Early & Surgical Prevention
In the emergency phase, protecting these three basic physiological processes helps prevent additional neurological injury.
What are oxygenation/ventilation, circulation/perfusion, and spinal alignment/protection?
For patients at risk of increased ICP, this simple positioning intervention promotes venous drainage from the brain.
What is elevating the head of the bed approximately 30 degrees
This neurological assessment includes level of consciousness, pupil size/reactivity, sensation, movement, and routine vital signs.
What are neurovitals/neurological observations?
Your postoperative TBI patient was previously alert but is now increasingly difficult to arouse. Their oxygen saturation remains unchanged.
What is the priority nursing interpretation?
What is possible neurological deterioration requiring immediate reassessment and escalation?
A family asks what neurological changes they should report immediately. What should the nurse reinforce?
What are new weakness, worsening headache, seizures, altered LOC, or other sudden neurological changes?
This procedure temporarily removes part of the skull to provide space for a severely swollen brain.
What is a decompressive craniectomy?
What is the recommended ICP?
What is below 20
Bradycardia, widening pulse pressure, and Cheyne-Stokes breathing form this late neurological warning sign.
What is Cushing’s triad?
A TBI patient develops repeated vomiting, worsening headache, and declining LOC. What complication should the nurse prioritize?
What is increasing intracranial pressure?
Your postoperative neurological patient develops difficulty speaking and swallowing. Which interdisciplinary team member should you consult?
Who is the Speech-Language Pathologist
This device can drain cerebrospinal fluid and help monitor intracranial pressure
What is an external ventricular drain, or EVD?
Because hypertonic therapy pulls fluid into the vascular space, nurses should closely monitor for crackles, respiratory distress, and this serious complication.
What is pulmonary edema/fluid overload?
A patient has decreased cerebral perfusion, unstable ICP, and a fever following a cerebral hemorrhage. Which intervention may be used to control temperature and reduce cerebral metabolic demand?
What is Targeted Temperature Management (TTM)?
A postoperative spinal cord patient has:
Which type of shock should the nurse consider?
What is neurogenic shock?
What should the nurse educate a postoperative neurological patient about regarding mobility and activity?
What is following ordered mobility restrictions, avoiding straining or excessive exertion, maintaining proper alignment, and asking for assistance before mobilizing?