NSG 233 Med Surg Exam 2 – Questions With
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Terms in this set (92)
Types of Brain Injury -- Concussion Temporary loss of neurological function
No structural damage to brain
Patient can be safe back to the activities once he
feels better
What the nurse should monitor for a Monitor for worsening neurological symptoms:
patient who had a concussion?
Vometing 🤢(projectile)
Seizures
Worsening headache
Irritability
Slurred speech
Confusion
Weakness
,What is the Monro-Kellie is that the sum of volumes of brain, CSF, and
doctrine/hypothesis? intracranial blood is constant. An increase in one
should cause a decrease in one or both of the
remaining two.
Components:
1 brain tissue
2 cerebrospinal fluid
3 intracranial blood
It helps explain how changes in the volume of one
component can affect the others and the overall
intracranial pressure (ICP).
Regulation & Maintenance of ICP Normal ICP = 5-15 M HG
• generally, treatmet is considered if ICP is sustained
greater than 20 mm hg
•elevation of ICP Over 20 should be report STAT!
Method of measuring ICP External ventricular drainage EVD
Also know as ventrucolostomy
It has 2 function drain spinal cord fluid and measure
ICP
,Types of head injury Open traumatic brain injury:
Occurs when there is a fracture of the skull or
penetration of the skull by an object
Closed traumatic brain injury: is the result of blunt
trauma ( more serious because of chance of
increased ICP in closed vault)
TBI (traumatic brain injury) nurse Administer stool softener
management to prevent complication Ensure ongoing nutritional support
Anticipate administration of an anticonvulsant
Monitor for HYPOnatremia
Is a result of inflammation from a brain Cerebral edema ——> increased ICP
trauma ?
What is the treatment for ICP ? Mannitol (Osmotic diuretic) + 3% ns
-manage oliguria and anuria
-prevent acute renal failure
never give this to pt wih cerebral hemorrhage
IV infusion is usually adjusted to urine output,filter
and watch for crystals
Never give a client with no urine output (anuria); if
output is less 30 ml/hr, accumulation can cause
pulmonary edema
Hypertonic IV fluids 3 %
, what are some clinical manifestations Change in level of consciousness is an early sign
of EARLY increased ICP? Irritability, restlessness and decreased mental status
Flattening of affect—>drowsiness—>seizures—>coma
—>death
Cushing triad
Widened pulse, increased systolic blood pressure
Bradycardia
Nuchal rigidity ( can not flex Chin to chest )
Change in body temperature due to effects on
hypothalamus
What is Cushing's triad in ICP ? Profundity hypertension and bradycardia with
decreased or irregular respirations ( cheyne stokes )
due to brain stem compression
Don't confuse it with neurological shock which is
hypotension and tacky
Appropriate Solutions
Save Groups
Terms in this set (92)
Types of Brain Injury -- Concussion Temporary loss of neurological function
No structural damage to brain
Patient can be safe back to the activities once he
feels better
What the nurse should monitor for a Monitor for worsening neurological symptoms:
patient who had a concussion?
Vometing 🤢(projectile)
Seizures
Worsening headache
Irritability
Slurred speech
Confusion
Weakness
,What is the Monro-Kellie is that the sum of volumes of brain, CSF, and
doctrine/hypothesis? intracranial blood is constant. An increase in one
should cause a decrease in one or both of the
remaining two.
Components:
1 brain tissue
2 cerebrospinal fluid
3 intracranial blood
It helps explain how changes in the volume of one
component can affect the others and the overall
intracranial pressure (ICP).
Regulation & Maintenance of ICP Normal ICP = 5-15 M HG
• generally, treatmet is considered if ICP is sustained
greater than 20 mm hg
•elevation of ICP Over 20 should be report STAT!
Method of measuring ICP External ventricular drainage EVD
Also know as ventrucolostomy
It has 2 function drain spinal cord fluid and measure
ICP
,Types of head injury Open traumatic brain injury:
Occurs when there is a fracture of the skull or
penetration of the skull by an object
Closed traumatic brain injury: is the result of blunt
trauma ( more serious because of chance of
increased ICP in closed vault)
TBI (traumatic brain injury) nurse Administer stool softener
management to prevent complication Ensure ongoing nutritional support
Anticipate administration of an anticonvulsant
Monitor for HYPOnatremia
Is a result of inflammation from a brain Cerebral edema ——> increased ICP
trauma ?
What is the treatment for ICP ? Mannitol (Osmotic diuretic) + 3% ns
-manage oliguria and anuria
-prevent acute renal failure
never give this to pt wih cerebral hemorrhage
IV infusion is usually adjusted to urine output,filter
and watch for crystals
Never give a client with no urine output (anuria); if
output is less 30 ml/hr, accumulation can cause
pulmonary edema
Hypertonic IV fluids 3 %
, what are some clinical manifestations Change in level of consciousness is an early sign
of EARLY increased ICP? Irritability, restlessness and decreased mental status
Flattening of affect—>drowsiness—>seizures—>coma
—>death
Cushing triad
Widened pulse, increased systolic blood pressure
Bradycardia
Nuchal rigidity ( can not flex Chin to chest )
Change in body temperature due to effects on
hypothalamus
What is Cushing's triad in ICP ? Profundity hypertension and bradycardia with
decreased or irregular respirations ( cheyne stokes )
due to brain stem compression
Don't confuse it with neurological shock which is
hypotension and tacky
