NR 325 Exam 2
what are s/s of head injury? (Answer)- leakage of CSF
Ecchymosis
Battle’s sign/raccoon eyes
what is management of head injury? (Answer)- ensure patient airway*
priority
what is the Monro-Kellie doctrine? (Answer)- If one component increases, another
must decrease to maintain ICP.
only applicable to closed skull patients*
what is normal ICP level? (Answer)- 5-15mmHg
20mmHg needs treatment!!
What are key features of increased ICP? (Answer)- CUSHINGS TRIAD
lethargy to coma
change in speech
cranial nerve dysfunction
seizures
abnormal posturing
what is cushings triad? (Answer)- elevated BP, Decreased pulse, and decreased
respirations.
KEY characteristic of increased ICP
how do we manage patients leaking CSF? (Answer)- raise head of bed
NO sneezing/blowing nose/bleeding
NO NG tube, nasotracheal suctioning
How do we place a patient with increased ICP? (Answer)- elevated HOB atleast 30
degrees
what is the treatmet for increased ICP? (Answer)- maintain AIRWAY*
Hyperventilate patient to “blow off” CO2 (CO2 dilates blood vessels)
Raise HOB
Decrease metabolic demands by paralyzing and sedating patient
Mannitol- only diuretic given for ICP *
corticosteroids
Pain management
Intracranial monitoring (in ventricle)
Craniotomies- removes portion of skull to allow for brain to swell.
Decompressive craniectomy
what is the ONLY diuretic given for increased ICP? (Answer)- Mannitol
what are risk factors of stroke? (Answer)- Obesity
Heart disease
Diabetes mellitus
Hypercholesterolemia
Hypercoagulable states
Cocaine, illicit drug use
Atrial fibrillation- develop into clot, clot causes stroke
what type of seizure is this?
daydraming seizure- staring off into space (Answer)- absence- petit mal
usually occurs in children/young adolecense
hyperventilation and flashing lights can precipitate absence seizures
what type of seizure is this?
muscle stiffening followed by JERKING.
patients will fall if they are standing (Answer)- tonic clonic- grand mal