MED SURG NEURO

Question 1

Human responses to Increased ICP- EARLY

Answer 1

1) Earliest sign- change in LOC**
2) weakness- on one extremity/side
3) Headache- constant
4) Impaired ocular movements
5) Pupillary changes- size or constriction

Question 2

Human responses to increased ICP- LATE

Answer 2

•	Further deterioration of LOC   
•	Respiratory pattern alterations
•	Loss of brainstem reflexes
o	Pupillary, gag/swallowing, corneal 
•	Cushing’s Triad
o	1) Hypertension/widening pulse pressure
o	2) Bradycardia
o	3) Bradypnea
•	Hemiplegia or flaccidity
•	Posturing
o	Decorticate
o	Decerebrate

Question 3

How are nursing interventions for increased ICP grouped by?

Answer 3

grouped according to the specific human response that is being manifested. Not all of them are always done all the time. It is your critical thinking that will let you choose the most appropriate one for that specific patient manifesting that specific human response at that specific time.

Question 4

Risk for Compromise: Cerebral perfusion

Answer 4

• Elevate HOB slightly
o 30-45 degrees
o Head in neutral position – cervical collar if needed to keep head neutral
• Position to avoid extreme hip flexion
o If hips flexed dramatically it can increase pressure in chest up to the head
• Note abdominal distension
• Avoid Valsalva maneuver
o Ask patient to exhale when being moved or turned
o No closed mouth coughing
• Avoid enemas, suppositories
• Avoid isometric exercises that increase SBP
• Pre-oxygenate and hyperventilate prior to suctioning
• Avoid high levels of PEEP (+ end expiratory pressure)
• Space nursing interventions – don’t try to do everything at once!
• Assess level of cognition, orientation, and ability to follow commands
• Avoid emotional distress and frequent arousal from sleep

Question 5

Risk for compromise: Airway Clearance

Answer 5

• Elevate HOB
• Auscultate lung fields
• O2 as needed
• Monitor pulse ox
• Suction as needed – if producing secretions they cannot manage
• Hyperoxygenation for suctioning  suctioning of nares is a no-no b/c so close to brain
• Note nasal drainage – what it looks like & how much

Question 6

Risk for compromise: Fluid Balance/Imbalance

Answer 6

•	Monitor vital signs
•	Monitor I & O
•	Monitor skin turgor, mucous membranes, serum and urine osmolality
•	Monitor IVF carefully
•	Observe for CHF and pulmonary edema if giving Mannitol 
•	Good oral hygiene
o	Non-drying mouth rinse
o	Lip lubrication d/t mouth breathing

Question 7

Risk for compromise: Bowel/bladder function

Answer 7

• Monitor urinary output every 2-4 hours
• Test urine for specific gravity and glucose
• Monitor bowel sounds
• Monitor for abdominal distension
• Test stools for occult blood

Question 8

Risk for compromise: infection

Answer 8

• Aseptic technique when managing the intra-ventricular catheter/direct ICP monitoring
• Observe character of the CSF drainage
o Report increasing cloudiness or blood (could be indicative of infection)
o CSF means there is an opening in the brain somewhere!!!
• Monitor for signs/symptoms of meningitis
o Fever, chills, nuchal rigidity, increasing/persistent headache
• Monitor temperature, labs, urine, lungs

Question 9

Risk for compromise: Miscellaneous

Answer 9

•	Hyperventilation  want to keep CO2 in bloodstream down 
o	PaCO2 range:  25-30 mm Hg
•	Temperature control
o	Prevent hyper- or hypothermia
•	B/P control
o	High range normal essential for adequate perfusion pressure
o	Too high may increase ICP
o	Sedation

Question 10

What to do if someone is having a seizure

Answer 10

Maintain and protect airway  keeps tongue from dropping back into throat 
o	Suction set-up available
o	Turn sideways
o	Intubation to protect airway? 
•	Limit seizure duration
o	Medications 
	Valium (diazepam), Ativan (lorazepam), Dilantin (phenytoin)
•	Prevent patient/personal injury
•	Observe seizure activity
o	Neuro/cardio/pulmonary monitoring   
•	Documentation

Question 11

What to do post seizure

Answer 11

•	Reorient patient when awake
•	Provide comfort and reassurance
•	Treat any injury from seizure activity
•	Maintain seizure precautions – protect from injury! 
•	Anti-seizure medication if ordered
•	Education
o	Medication – skipping medication will only increase chance of seizures 
o	Triggers
o	At-home/school care

Question 12

Status epilepticus

Answer 12

want to stop seizures ASAP to stop activities from using up oxygen in brain & causing hypoxia 
•	Limit seizure duration
o	IV Medications 
	Valium (diazepam)
	Ativan (lorazepam)
	Dilantin (phenytoin)
•	Establish and protect airway
o	Turn sideways
o	Intubation may be necessary
•	Neuro/cardio/pulmonary monitoring
•	Maintain safety
•	Documentation

Question 13

Diabetes insipidus

Answer 13

-is due to HIGH URINE OUTPUT NOT GLUCOSE

Question 14

Nursing management for diapetes insipidus

Answer 14

•	DI (Drains out)
o	Monitor urinary output
o	Monitory daily weight (loss)
o	Monitor for dehydration
	Secondary to huge urine output
o	Monitor lab values
	Urine/serum osmolarity  
	Serum electrolytes – lose dilute fluid but retain sodium so levels get high
•	Na+> 140 mEq = dehydration
o	Document

Question 15

SIAH nursing management

Answer 15

o	Monitor urinary output
o	Monitory daily weight (gain)
o	Restrict fluids – tries to balance out serum sodium & water 
	Addresses low serum Na+
o	Monitor lab values
	Urine/serum osmolarity  
	Serum electrolytes
•	Na+ < 135 = confusion
o	Monitor mentation
o	Document