NR 325 exam 2 (nicole_kleber)
leakage of CSF
Ecchymosis
Battle's sign/raccoon eyes - ANS-what are s/s of head injury?
ensure patient airway*
priority - ANS-what is management of head injury?
If one component increases, another must decrease to maintain ICP.
only applicable to closed skull patients* - ANS-what is the Monro-Kellie doctrine?
5-15mmHg
>20mmHg needs treatment!! - ANS-what is normal ICP level?
CUSHINGS TRIAD
lethargy to coma
change in speech
cranial nerve dysfunction
seizures
abnormal posturing - ANS-What are key features of increased ICP?
elevated BP, Decreased pulse, and decreased respirations.
KEY characteristic of increased ICP - ANS-what is cushings triad?
raise head of bed
NO sneezing/blowing nose/bleeding
NO NG tube, nasotracheal suctioning - ANS-how do we manage patients leaking CSF?
elevated HOB atleast 30 degrees - ANS-How do we place a patient with increased ICP?
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 - ANS-what is the treatmet for increased ICP?
Mannitol - ANS-what is the ONLY diuretic given for increased ICP?
Obesity
Heart disease
Diabetes mellitus
Hypercholesterolemia
Hypercoagulable states
Cocaine, illicit drug use
Atrial fibrillation- develop into clot, clot causes stroke - ANS-what are risk factors of stroke?
absence- petit mal
usually occurs in children/young adolecense
hyperventilation and flashing lights can precipitate absence seizures - ANS-what type of seizure
is this?
daydraming seizure- staring off into space
tonic clonic- grand mal - ANS-what type of seizure is this?
muscle stiffening followed by JERKING.
patients will fall if they are standing
myoclonic - ANS-what type of seizure is this?
contractions of body muscles; sudden excessive jerk or twitch of extremities
atonic - ANS-what type of seizure is this?
go "limp", drop attacks (fall to the ground)
leakage of CSF
Ecchymosis
Battle's sign/raccoon eyes - ANS-what are s/s of head injury?
ensure patient airway*
priority - ANS-what is management of head injury?
If one component increases, another must decrease to maintain ICP.
only applicable to closed skull patients* - ANS-what is the Monro-Kellie doctrine?
5-15mmHg
>20mmHg needs treatment!! - ANS-what is normal ICP level?
CUSHINGS TRIAD
lethargy to coma
change in speech
cranial nerve dysfunction
seizures
abnormal posturing - ANS-What are key features of increased ICP?
elevated BP, Decreased pulse, and decreased respirations.
KEY characteristic of increased ICP - ANS-what is cushings triad?
raise head of bed
NO sneezing/blowing nose/bleeding
NO NG tube, nasotracheal suctioning - ANS-how do we manage patients leaking CSF?
elevated HOB atleast 30 degrees - ANS-How do we place a patient with increased ICP?
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 - ANS-what is the treatmet for increased ICP?
Mannitol - ANS-what is the ONLY diuretic given for increased ICP?
Obesity
Heart disease
Diabetes mellitus
Hypercholesterolemia
Hypercoagulable states
Cocaine, illicit drug use
Atrial fibrillation- develop into clot, clot causes stroke - ANS-what are risk factors of stroke?
absence- petit mal
usually occurs in children/young adolecense
hyperventilation and flashing lights can precipitate absence seizures - ANS-what type of seizure
is this?
daydraming seizure- staring off into space
tonic clonic- grand mal - ANS-what type of seizure is this?
muscle stiffening followed by JERKING.
patients will fall if they are standing
myoclonic - ANS-what type of seizure is this?
contractions of body muscles; sudden excessive jerk or twitch of extremities
atonic - ANS-what type of seizure is this?
go "limp", drop attacks (fall to the ground)
