NEUROLOGICAL Flashcards
(20 cards)
What are the three components occupying the intracranial space?
- Blood (10%)
- Cerebrospinal Fluid (CSF) (10%)
- Brain tissue (80%)
What is the normal physiologic range for Intracranial Pressure (ICP)?
0 to 15 mmHg
What ICP value requires immediate medical intervention?
> 15 mmHg (sustained)
What are the etiologies of increased ICP?
- Increase in brain volume due to traumatic brain injuries, brain tumors, or brain abscesses
- Increase in cerebral blood volume caused by hypoxemia, hypercapnia, or venous outflow obstruction
- Increase in CSF due to meningitis, encephalitis, or cerebral hemorrhage
List clinical manifestations of increased ICP.
- Deterioration in level of consciousness (confusion, drowsiness)
- Changes in pupillary response to light
- Hemiparesis or hemiplegia
- Abnormal motor responses (decorticate and decerebrate posturing)
What is a major complication of increased ICP?
Brain stem herniation
What nursing diagnoses are common for increased ICP?
- Ineffective cerebral tissue perfusion related to increased ICP
- Risk for injury related to altered level of consciousness or seizures
- Ineffective airway clearance related to diminished protective reflexes
- Risk for infection related to ICP monitoring devices
- Fluid volume deficit related to altered level of consciousness
- Imbalanced nutrition related to inadequate intake
What are the overall planning goals for a patient with increased ICP?
- Maintain a patient airway
- ICP within normal limits
- Normal fluid and electrolyte balance
- No complications secondary to immobility and decreased level of consciousness
What nursing considerations are important for managing increased ICP?
- Elevate the head
- Administer analgesics for headaches
- Maintain head and neck in a neutral midline position
- Avoid hip flexion
- Prevent hyperthermia
- Provide a laxative to prevent constipation
- Elevate head and trunk up to 30 degrees
What are brain tumors?
Space-occupying intracranial lesions that can be benign or malignant, and primary or secondary
What are common signs and symptoms of brain tumors?
- Alterations in consciousness
- Motor and visual disturbances
- Headaches
- Seizures
- Vomiting (potentially sudden and projectile)
What nursing diagnoses are relevant for a patient with a brain tumor?
- Impaired tissue perfusion (cerebral) related to cerebral edema
- Acute pain (headache) related to cerebral edema and increased ICP
- Self-care deficits related to altered neuromuscular function
What are the common causes of traumatic head injury?
- Transportation accidents
- Falls
- Violence
- Sports-related injuries
What types of head injury exist?
- Scalp laceration
- Skull fracture
- Brain injury (minor like concussion, major like contusion, epidural hematoma, subdural hematoma, intracerebral hematoma)
What manifestations are associated with skull fractures?
- Facial paralysis
- Rhinorrhea (CSF leakage from the nose)
- Otorrhea (CSF leakage from the ear)
- Raccoon eyes (periorbital edema and ecchymosis)
What are major potential complications of skull fractures?
- Internal infections
- Hematoma
- Brain tissue damage
What general measures are important for brain injury management?
- Management of airway/oxygenation
- Maintaining blood pressure
- Monitoring conscious level
- Proper head position
- Temperature control
- Fluid management
What classifications exist for strokes?
- Hemorrhagic
- Ischemic
What are common manifestations of stroke?
- Sudden severe headache
- Nausea and vomiting
- Confusion or change in mental status
- Numbness or weakness
- Hemiplegia
- Aphasia
- Dysphagia
- Visual disturbance
What are major nursing diagnoses for a patient with a stroke?
- Impaired physical mobility related to hemiparesis
- Acute pain related to hemiplegia
- Self-care deficits related to stroke sequelae
- Disturbed sensory perception
- Impaired swallowing
