Summary
Summary NUR 265 Exam 3 Study Guide
- Course
- ATI NUR265
- Institution
- Galen College Of Nursing
This is a comprehensive and detailed study guide on Exam 3. *Essential Study Material!!
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Exam 3 Study GuideLabs:
ICP: 10-15
Hgb: 12-18
Hct: 37-52
WBC: 5-10
Plate: 150-400
K: 3.5-5
Mg: 1.5-2.5
Chloride: 98-106
AST: 0-35
ALT: 4-36
PT: 11-12.5
INR: 0.9-1.2
BUN: 10-20
Cr: 0.6-1.2
Meds:
Vasopressor- constricts blood vessels which increases BP and cardiac output. Tx for shock.
Phenylephrine
Norepinephrine
Epinephrine
Vasopressin
Dopamine- Inotrope, increases the contraction of the heart, increasing BP and cardiac output.
Improves blood flow to the kidneys
Interferon- Tx for MS
Atropine- raises BP
Mannitol- diuretic used to lower ICP. Administer using filter d/t crystals
Pyridostigmine- treats MG
Improves muscle strength
Eat meals 45-60 minutes BEFORE eating to prevent aspiration
Keep meds at bedside with full glass of water
Monitor blood levels
Other MG meds are immunosuppressants, methotrexate, rituximab, corticosteroids
Warfarin- blood thinner/prevents clots, monitor PT/INR (11-12.5/0.9-1.2 three times more on
therapy), vitK is antidote, avoid leafy greens and grapefruit juice
Lorazepam- benzodiazepine Tx seizures
Vancomycin- broad spectrum ATB
Enoxaparin- sub-Q anticoagulant
Regular insulin- short acting insulin can only be given IV. May tx hyperkalemia
Cefazolin- broad spectrum ATB
Nitroprusside- vasoactive medication can only be given through a central line
Inotrope- used to tx cardiogenic shock by increasing the contractility and cardiac output.
Dopamine, epinephrine, norepinephrine, digoxin
, NEURO
Head Injury:
-Most common causes are motor vehicle accidents, falls, and sports injuries (trauma)
Can be blunt or penetrating trauma.
Injury to the scalp, skull, or brain
-Highest risk is 15-24 males
-If a patient is on blood thinners and falls it can be more serious
PATHO of tbi- trauma, brain swells or bleeds causing increased icp, cranium allows no room for
the brain to swell, increased icp causes vessels to swell and causes blood flow to the brain to
slow, cerebral hypoxia and ischemia can occur, pressure still rises, cerebral blood flow ceases.
Basilar Skull Fractures: look for a halo sign. Could be serious because of how close it is
to midbrain/cerebral arteries.
S/S- ALL THESE EXPECTED
headache or pain at the point of impact.
a bump or bruise.
bleeding from a wound.
bleeding from the ears, nose, or eyes.
bruising behind the ears or under the eyes- battles sign- signs of middle cranial fossa break
feeling drowsy, confused, or irritable.
loss of speech or slurred speech.
Nursing Management-
Watch closely for irritability/restlessness, they are at risk for increased ICP- THIS IS THE
BIGGEST PRIORITY BECAUSE THIS IS A COMPLICATION
Apply cold packs
Turn q 2 hours
Elevate HOB to prevent edema
COMPLICATIONS
Make sure they do not have a csf leak!! Observe for clear ear drainage or clear nasal drainage
because it can be CFS- will have high glucose level
Halo sign – clear yellowish ring on tissue
Suctioning – Do NOT perform if the patient has nasal leakage
, Closed Brain Injury: integrity of the skull is not compromised. Complication of initial
injury
-The head injury (blunt trauma) has already occurred, and we can’t change that, so we worry
the most about secondary injuries such as increased ICP and cerebral edema
-Increased ICP/cerebral edema causes hypoxia then the brain doesn’t get blood flow and can
die
-Infection is a risk if something went through the skull
Open/Direct (primary) Brain Injury- Integrity of the skull, dura, and brain compromised, can be
caused by gunshot wound/ penetrating wound. Direct damage done to the brain. Irreversible.
Secondary Brain injury- Need to catch these asap- can be caused by ICP, legion/mass
expansion, bleeding, or hydrocephalus, or can be caused by increased icp/brain herniation. Can
have lower map than 65 and o2 lower than 80%
Brain Injury: FIRST PRIORITY ABC’S
S/S- ALL THESE EXPECTED WITH A BRAIN INJURY!!
Altered level of consciousness (biggest indicator)
Pupillary abnormalities (dilated indicates cerebral edema)
Sudden onset of neurological deficits and neurological changes; changes in sense, movement,
trouble speaking, and reflexes.
Headache
You can expect seizures, but they should not be having them! Brains way of protecting itself
from the pressure!
COMPLICATIONS!!! WATCH FOR THESE
Nausea and Vomiting (if it is persistent and severe then they need to go to the emergency
room/call MD because it is a sign of increased ICP)- THIS IS A COMPLICATION OF ALL
BRAIN INJURYS/HEAD INJURIES
Changes in vital signs. (Decrease pulse, decrease in respirations, and widening pulse
pressure is called Cushing’s triad. Recognize this early and intervene quickly). THEY
ARE ABOUT TO HERNIATE ONTO THEIR BRAINSTEM AND DIE CALL DOC
Posturing: Decorticate (pulled up like a cord) and decerebrate (late signs and symptoms)- only
10% survival with that.
Nursing Management-
THIS IS WHAT WE NEED TO DO WHEN THERE IS A BRAIN/HEAD INJURY!!! ABC’S,
Spinal precautions, Vitals, Neuro assessment, prevent secondary brain injury!
Always assume cervical spine injury until ruled out. - can’t be off the board until imaging.
Preserve brain homeostasis and prevent secondary damage. You need to watch for increased
ICP because this can cause a secondary brain injury!!
Treat cerebral edema- usually give mannitol bolus
Maintain cerebral perfusion- HEAD AND NECK MIDLINE HOB 30 DEGREES
Increased CO2 levels increase vasodilation – increases ICP
Maintain oxygenation, cardiovascular, and respiratory function- could possibly be ventilated due
to pressure on the brain stem which impairs breathing function
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