Week 5 THURS Flashcards
adult neuro
What is a priority nursing intervention for a pt who is unconscious?
maintain pt airway
During an active seizure the nurse should?
place client on their side, remove dangerous objects, and protect their head
What intervention should the nurse implement to prevent increases in ICP?
Elevate HOB 30 degrees
What is the earliest sign of increased ICP?
Change in LOC
A client is sitting in a chair and begins having a tonic-clonic seizure. What is the most appropriate nursing response?
- carefully move client to a flat surface and turn them on their side
A client has an altered LOC due to blunt force trauma to the head. The nurse should first gauge the clients LOC on the result of what diagnostic tool?
Glasgow Coma Scale
What score indicates severe impairment of neurologic function on the GCS?
3
Assessing a clients pupils, what reaction would confirm increasing ICP?
- fixed and dilated
- unequal response
the cranial vault contains three components which are……
- blood 10-12%
- CSF 8-10%
- brain tissue 80%
T or F CSF is the most easily displaced fluid in the cranial vault
TRUE!
The pressure that soft contents of cranial vault against the rigid cranial bones
Intracranial pressure
What is normal Intracranial pressure?
0-15mm HG
- anything above 20 for five minutes or more needs to be treated
2 Factors that impact neurological status
- intracranial pressure
- cerebral perfusion pressure
the amount of pressure required to provide blood flow to the brain
cerebral perfusion pressure
MAP-ICP=?
CPP> cerebral perfusion pressure
Normal adult range for CPP?
70-100
If any one component increases, 1 or 2 of the other components need to decrease— failure to maintain balance (greater than 100% or less than 100%) = higher ICP or lower ICP
Monroe Kellie hypothesis
Increased intracranial pressure has 3 factors that are increased
- increased brain volume
- increased cerebral blood volume
- increased CSF
What happens if CPP falls too low?
the brain and brian tissue are not perfused
ICP= 30, BP=120/80, MAP= 93
what is the CPP?
120+2(80)/3
CPP=93-30= 57
If ICP is HIGH then CPP is LOW
and if MAP is LOW then CPP is LOW .Tor F
True!
this is the rule of thumb for relationships
Interventions for low CPP
Raise HOB, Head alignment, limit stimulation, Mannitol(osmotic diuretic), fluid restriction, avoid any vasopressors
Interventions for high CPP
Fluid Bolus, vasopressors
HIGH CBV and CBF s/s
High systemic BP, avoid systemic acifosis, high metabolic rate (fever, pain), high cerebral edema
