NUR 2520 Unit 1 & 2 Questions With Complete Solutions
Herniation Flow chart
Inc Volume of CSF, blood, or tissue
(mass/tumor/abscess/edema)
⬇️
Increased ICP
⬇️
Decreased Cerebral Blood Flow
⬇️
Decreased Cerebral Perfusion Pressure
⬇️
Brain Ischemia/Infarction
⬇️
Edema
⬇️
Increased Compression
⬇️
Herniation
⬇️
💀
Head Injurry/TBI
Common with Head Trauma
Severity depends on mechanism of injury
TBI Complications
,High Risk for hemorrhage or CF leak
(Bone compression or fragments press on the tissue or get into
cerebral circulation
TBI symptoms
**S/S will vary depending on location
Some are:
Cranial nerve deficits
Battle Sign (Postauricular Ecchymosis)
Raccoon Eyes (periorbital ecchymosis)
Rhinorrhea
Otorrhea
Recognizing CSF fluid
Use Tes-Tape or Dextrostix to test for the presence of glucose
(CSF will have glucose, Snot will not)
Recognizing CSF fluid with Bloody sample
Collect sample on clean gauze
Look for halo/ring around blood (this is the CSF)
TBI interventions
Cranial surgery
ICP drain
obtain baseline Glasgow coma scale and frequent Nuro checks
to assess for even slight changes
Maintain cerebral oxygenation and perfusion
medication (anti-seizure, anti-emetic, pain management)
Maintain normal temp
***lumbar puncture is contraindicated
, TBI complications
Increased ICP
monitor for Cushing's triad
hematoma
subdural hemorrhage (often venous)
Epidural hematoma (often from arterial tears or ruptures) -
**EMERGENT SURGICAL EVACUATION
Cushing's triad
three classic signs—bradycardia, hypertension, and bradypnea—
seen with pressure on the medulla as a result of brain stem
herniation
Treatment for acute intracranial issues
Identify and treat cause
decreased ICP
oxygenation to support brain function
cranial surgery (burr holes, craniotomy, craniectomy)
Optimize ICP and CPP (positioning, elevate HOB 30°, no
activities that increase intra-ABD or intra-thoracic pressure)
Minimize complications of immobility
protect from injury
Decrease metabolic demand (stop shivering)
Medication treatment for acute intracranial issues
Mannitol
Prophylactic anti-seizure medication
Corticosteroids
antipyretics
Herniation Flow chart
Inc Volume of CSF, blood, or tissue
(mass/tumor/abscess/edema)
⬇️
Increased ICP
⬇️
Decreased Cerebral Blood Flow
⬇️
Decreased Cerebral Perfusion Pressure
⬇️
Brain Ischemia/Infarction
⬇️
Edema
⬇️
Increased Compression
⬇️
Herniation
⬇️
💀
Head Injurry/TBI
Common with Head Trauma
Severity depends on mechanism of injury
TBI Complications
,High Risk for hemorrhage or CF leak
(Bone compression or fragments press on the tissue or get into
cerebral circulation
TBI symptoms
**S/S will vary depending on location
Some are:
Cranial nerve deficits
Battle Sign (Postauricular Ecchymosis)
Raccoon Eyes (periorbital ecchymosis)
Rhinorrhea
Otorrhea
Recognizing CSF fluid
Use Tes-Tape or Dextrostix to test for the presence of glucose
(CSF will have glucose, Snot will not)
Recognizing CSF fluid with Bloody sample
Collect sample on clean gauze
Look for halo/ring around blood (this is the CSF)
TBI interventions
Cranial surgery
ICP drain
obtain baseline Glasgow coma scale and frequent Nuro checks
to assess for even slight changes
Maintain cerebral oxygenation and perfusion
medication (anti-seizure, anti-emetic, pain management)
Maintain normal temp
***lumbar puncture is contraindicated
, TBI complications
Increased ICP
monitor for Cushing's triad
hematoma
subdural hemorrhage (often venous)
Epidural hematoma (often from arterial tears or ruptures) -
**EMERGENT SURGICAL EVACUATION
Cushing's triad
three classic signs—bradycardia, hypertension, and bradypnea—
seen with pressure on the medulla as a result of brain stem
herniation
Treatment for acute intracranial issues
Identify and treat cause
decreased ICP
oxygenation to support brain function
cranial surgery (burr holes, craniotomy, craniectomy)
Optimize ICP and CPP (positioning, elevate HOB 30°, no
activities that increase intra-ABD or intra-thoracic pressure)
Minimize complications of immobility
protect from injury
Decrease metabolic demand (stop shivering)
Medication treatment for acute intracranial issues
Mannitol
Prophylactic anti-seizure medication
Corticosteroids
antipyretics
