NUR 265 Exam 3 Study Guide & Exam Questions and Answers.

NUR 265 Exam 3 Study Guide & Exam Questions and Answers.Increased ICP (939-940, chart 941) • Normal ICP 10-15 mmHg, pressures >20 mmHg impair cerebral circulation • IICP is leading cause of death from head trauma in pts who reach the hospital alive. • Cerebral Perfusion Pressure (CPP) o Blood flow required to provide adequate oxygenation & glucose for brain metabolism o Maintenance above 70 mmHg o CPP= MAP-ICP ▪ MAP= (2xD) + S MAP NEEDS TO BE ATLEAST 80 3 • Compensation o First Response – CSF is shunted or displaced into the spine (compliance) o Next – Reduction of blood volume in the brain (autoregulation) o As ICP continues to increase cerebral perfusion decreases leading to brain tissue ischemia, edema, vasodilation then acidosis which causes further increases ICP o In edema remains untreated the brain may herniate into spinal canal – death from brain stem compression • Assessment Findings o Changes in LOC – First sign of IICP is declining LOC & includes restlessness or confusion to Stuporous ▪ W/o glucose & 02, brain shuts down. Ex. Pt knew who you were in am & now don’t remember o Headache – Quite environment may have photophobia so keep room lights very low. o Change in speech pattern – Aphasia, Slurred Speech o Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify Dr Normal is 6 mm. Getting better if going back toward normal from dilated or constricted ▪ Uneven pupils tx as IICP until proven otherwise; pinpoint - brain stem (pons) dysfunction o Abnormal Posturing – Decorticate (flexion) or Decerebrate (extensor) ▪ Decorticate – arms drawn to core, legs straight ▪ Decerebrate – arms straight and stiff, pts rarely survive o Hyperthermia – followed later by hypothermia ▪ When hypothermic – BE CONCERNED, pressure on hypothalamus located next to brain stem o Cardiac & respiratory rate/rhythm changes ▪ Tachy first – Increased HR & RR before brady HR & RR o N/V – Common in IICP o Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia ▪ Late response & indicates severe IICP w/loss of autoregulation, Imminent death ▪ Systolic BP increases bc decreased blood flow to brain ▪ Pressure on Vagus nerve and brainstem = bradycardia