NUR 2755 Multidimensional Care IV MDC 4 Rasmussen
Exam 9 2024
Understand treatments and nursing care for IICP, Increasing Intracranial Pressure - Maintain
airway patency.
Monitor neurological status; assessment areas include LOC, behavior, motor/sensory functions,
pupillary size and reaction to light, and vital signs.
Monitor IICP monitor orventilator.
Decrease stimuli.
Raise pads and bed rails; seizures may occur.
Elevate the head of bed 30 degrees unless otherwise indicated.
Monitor arterial blood gases.
Position client as prescribed.
Prevent complications associated with immobility.
Monitor fluid and electrolytes.
Monitor bladder distention and bowel constipation.
Provide emotional support as needed.
Administer medications as ordered.
Clients with IICP may undergo various intracranial surgical techniques to treat the underlying
cause. In addition, infarcted or necrotic tissue may be resected to reduce brain mass. A drainage
catheter or shunt may be inserted laterally via a burr hole into a ventricle to drain excess CSF and
reduce hydrocephalus. The removal of even a small amount of CSF may dramatically reduce
IICP and restore cerebral perfusion pressure.
Diuretics, particularly osmotic diuretics, are commonly used to reduce ICP and are the mainstays
of pharmacologic treatment. Loop diuretics such as furosemide (Lasix), the drug of choice, and
ethacrynic acid (Edecrin) may be prescribed for some clients with IICP. Antipyretics, such as
acetaminophen, are used alone or in combination with a hypothermia blanket to treat
hyperthermia. (Hyperthermia increases the cerebral metabolic rate and exacerbates an existing
increase in ICP.) Anticonvulsants are often required to manage seizure activity associated with
brain injury and IICP. Antihypertensives, in particular beta-blockers, may be used if the mean
arterial pressure (MAP) is high. Vasopressors may be used if the MAP is low. Gastrointestinal
prophylaxis with intravenous histamine H2 antagonists or proton pump
Monroe-Kelliw hypothesis - A hypothesis that states if the volume of any of the three
intracranial components (the brain, cerebrospinal fluid, and blood) increases, the volume of the
others must decrease to maintain normal pressures in the cranial cavity.
The normal ICP is 5-15 mmHg (measured intracranially with a pressure transducer while the
client is lying with the head elevated 30 degrees) or 60-180 cm H2O (measured with a water
manometer while the client is lying in a lateral recumbent position).
Understand VP shunts, why they are needed, nursing interventions and teachings, complications
involved. - I know the book does not go over VP Shunts in great detail just mentions them as a
,treatment option for Hydrocephalus. A Ventriculoperitoneal shunt is a medical device used to
relieve IICP. It is basically a catheter starting in the head internally implanted and draining into
the peritoneum to relieve the excess CSF. You as the nurse will be in charge of teaching families
and patients complications involved. Complications would be the S+S of IICP. Just understand
what this device is for.
Nursing interventions for Head injury and goals associated with head injury - Nurses can help
clients prevent head injury by providing anticipatory guidance related to safe practices,
especially wearing protective equipment such as helmets when engaging in sports or activities
with a high risk for concussion.
Know the process of caring for MVA patients from the ED to home care - Nursing interventions
and associated complications involved with MVA
Maintain Airway Patency and Ventilation
Assess for Disability and Expose Obscured Areas
Promote Fluid Volume Balance
Prevent Infection
Promote Mobility
Offer Spiritual Comfort Measures
Promote Psychosocial Well-Being
Facilitate Community-Based Care
Mild head injury to brain, bruising, bleeding, and/or swelling
Tearing or injury to the posterior cruciate ligament of the knee, whiplash, spinal cord injury
either incomplete or complete
For the client who has sustained injury in a motor vehicle crash, primary consideration should be
given to the airway: Assess if the airway is patent, maintainable, or nonmaintainable. Assess for
manifestations of airway obstruction: stridor, tachypnea, bradypnea, cough, cyanosis, dyspnea,
decreased or absent breath sounds, changes in oxygen levels, and changes in level of
consciousness. Assessing the airway and initiating interventions are the first steps in managing
the client with multiple injuries. A cervical collar (or C-collar), which stabilizes and maintains
neutral alignment of the cervical spine, should be applied to clients with potential or suspected
cervical spine injury. Longboard spinal immobilization, which provides support and
immobilization of the entire spine below the level of the neck, should be instituted for clients
with a potential or suspected spinal cord injury. Cervical and longboard spinal immobilization
should be discontinued only by physician's order after determining that the client has not
sustained a spinal injury. Although not always needed, this determination may require evaluation
of the client's spine using CT scan.
Spinal cord injuries, nursing interventions treatments and medications - Immediate care will
include assistance with ventilation, immobilization, care of wounds, and bladder and bowel
control. Interventions during the recovery phase will include assistance with mobility, exercise,
and self-care activities and prevention of complications. Rehabilitation interventions will include
assistance with ambulation, training for ADLs, and referral to rehabilitation therapy.
, Most clients will receive high-dose methylprednisone within 8 hours after injury to improve
neurological recovery. Methylprednisone appears to decrease inflammation and reduce damage
to surrounding nerve cells. Adverse effects are usually minor. Prophylactic anticoagulation
therapy (e.g., heparin, Coumadin) may be given to help prevent DVT and pulmonary embolism.
Infections, especially pneumonia, should be treated promptly with appropriate antibiotics; pain
can be treated with opioids, NSAIDs, and other analgesics as needed.
After a SCI, surgery may also be needed to stabilize the spine. Spine stabilization may involve
realigning the spine and using instrumentation such as rods and screws to internally immobilize
the spine. A bone graft from the client or bone bank is often added to promote fusion of the
vertebrae. Surgery can also be performed to set up spinal traction using Gardner-Wells tongs or
other traction devices or external fixation with a halo brace. A halo brace is often used for clients
with cervical fractures without major cord damage. The client may be in traction or external
fixation for several weeks or months.
Nursing roles and care for spinal cord injuries, Bowel and Bladder training - Clients with a spinal
cord injury will require extensive nursing care. Immediate nursing care involves maintaining an
airway, assisting with ventilation, and immobilizing the client. Nursing care also includes
preventing complications such as urinary or bowel problems, pressure sores, and infection.
During the healing process, the nurse will also play a role in the client's rehabilitation and client
teaching for home care.
Bladder training, which requires that the client postpone voiding, resist or inhibit the sensation of
urgency, and void according to a timetable rather than according to the urge to void. The goals
are to gradually lengthen the intervals between occasions of urination to correct the client's
frequent urination, to stabilize the bladder, and to diminish urgency. This form of training may
be used for clients who have bladder instability and urge incontinence. Delayed voiding produces
larger voided volumes and longer intervals between instances of voiding. Initially, voiding may
be encouraged every 2-3 hours except during sleep, and then every 4-6 hours. A vital component
of bladder training is inhibiting the urge-to-void sensation: Every time the client has a premature
urge to void, repeat the instruction to practice deep, slow breathing until the urge diminishes or
disappears.
End of life Nursing Dx - Fear
Death Anxiety
Grieving related to impending death
Signs of end of life in terminally ill patients - Nausea
Dyspnea
Hypotension
Anorexia, nausea, and dehydration
Altered levels of consciousness
Pain
Psychosocial needs (say final good-byes, make final arrangements, cultural or religious
practices)
