ECCO Caring for Patients with Neurologic Disorders Part 1

ECCO Caring for Patients with Neurologic Disorders Part 1 Your patient blinks and can move eyes up and down. Respirations are irregular with periods of apnea; gag reflex and motor movement of extremities are absent. What is your highest priority intervention? Secure the airway A patient is admitted with a subarachnoid hemorrhage. She is restless and agitated, and complaining of an ongoing headache 10/10. Which of the following changes in signs and symptoms requires an immediate call to the provider? Unresponsiveness to physical stimuli and sluggish pupillary response When a nurse asks a patient's name, The patient replies with the name of the town where the hospital is located. When asked what day it is, he replies "house." Shown a hairbrush and asked to name it, he replies "dog." What other step(s) should the nurse take to evaluate the patient's language functioning? Ask the patient to raise one arm slowly. Patients who demonstrate components of aphasia need to be assessed for their ability to follow commands to help differentiate the type of aphasia. Avoid providing cues to the patient when asking them to follow commands. A patient with an external ventricular drain is noted to have a damped ICP waveform on the monitor. Which of the following is indicated? Check for air bubbles or debris in the drainage system A patient with a massive cerebral hemorrhage is admitted. The patient is comatose. Pupils have become dilated and no longer react to light. The breathing pattern has become irregular. Vital signs: BP 170/66 (101), HR 40 and irregular, RR 16 and irregular. Administration of which of the following should the nurse anticipate? Mannitol (Osmitrol) On a patient's ICP waveform, the P2 wave is higher and more rounded than the P1 wave. What is the significance of this finding? Decreased intracranial compliance; patient may be unable to compensate for intracranial volume changes. On the ICP waveform, P2 higher than P1 indicates the patient may be unable to compensate for small changes in intracranial volume. A nurse finds no CSF in a patient's EVD collection chamber. Assessment reveals the drain stopcock is open to drain. What two other assessment should the nurse perform? Assess for pulsations or fluctuations in the tubing