Altered LOC & ICP Flashcards Preview

ADN 214 > Altered LOC & ICP > Flashcards

Flashcards in Altered LOC & ICP Deck (21):
1

Frontal lobe

- speech
- thought
- emotion
- volunteer movement
- complicated cognitive process
- judgement reasoning
- concerns for others

2

Parietal lobe

- all sensory info
- shapes
- pain
- temperature
- 2 point discrimination (hot vs cold)

3

Occipital lobe

Process vision

4

Cerebellum

- control fine movement
- coordination
- balance position state
- awareness of position of body parts w/o looking at them

5

Brain stem

- controls reflexes
- influences all basic life function (breathing, HR, BP)

6

Temporal lobe

- stores memory
- interprets auditory stimuli

7

Consciousness-dynamic state

Being aware of oneself and the environment

8

Altered LOC causes

- lesions or injuries
- metabolic disorders (commonly hypoglycemia)
- meds
- direct or indirect pressure (masses, hematoma, cerebral edema)
- any systemic condition (usually impaired blood flow, hypoxemia, f/e imbalance, waste products and toxins d/t impaired hepatic or renal fxn)

9

Altered LOC manifestations

Changes in:
- pupillary response
- eye opening response
- verbal response
- motor response
- behavior (usually restlessness, increased anxiety)

10

Management of altered LOC

ABCs!!
- obtain/maintain patent airway
- monitor adequate perfusion
- IV access
- nutritional support
- med management
- prevention of complications

11

Normal ICP ranges

- infant: 1.5-6 mmHg
- children: 3-7 mmHg
- adults: 5-15 mmHg

12

How the brain compensates for increased ICP

- displacing or shifting CSF (increasing absorption, limiting production)
OR
- decreasing cerebral blood volume

13

What ICP requires IMMEDIATE intervention?

> 20 mmHg

14

Increased ICP: causes

- head injuries
- infections
- tumors
- stroke
- seizures
- hydrocephalus
- hypoxemia
- meningitis

15

Increased ICP: manifestations
EARLY

- decreased LOC
- lethargy
- confusion
- abnormal behavior
- restlessness

16

Increased ICP: manifestations
LATE

- comatose
- impaired memory/judgement
- headache
- vision changes-inability to move eyes up or down
- pupillary changes-sluggish or fixed
- projectile vomiting
- change in speech pattern (slurred, doesn’t make sense)
- aphasia
- changes in sensorimotor and motor fxn
- cranial nerve dysfunction
- ataxia
- seizures
- HTN
- abnormal posturing
- altered respiratory pattern

17

Cushing’s Traid - a late sign of increased ICP

- HTN
- widened pulse pressure
- bradycardia

18

Intracranial surgery: nursing role

- pre-op baseline assessment
- post-op monitoring and assessments
- reducing cerebral edema (diuretics, corticosteroids)
- monitor ICP

19

Increased ICP: teaching

- avoid coughing, blowing nose, straining
- maintain head and neck alignment
- take rest periods
- encourage family to talk to pt but avoid distressing conversations
- maintain a quiet environment w/ minimal stimuli

20

Posturing: decorticate

- arms are like Cs, “moves in toward the cord”
- problems with cervical spinal tract or cerebral hemisphere

21

Posturing: decerebrate

- arms are like Es
- problems with midbrain or pons