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Care of the Client with Nutritional & ... Chapter 15: Clinical Judgment to Red... EMT Ch 29 Chapter Test EM
183 terms 16 terms 43 terms 74
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Terms in this set (59)
Barbiturates - IV phenobarbitol (sedative, antiepileptic)
Traumatic brain injury (TBI)
Hydantoins - IV phenytoin (seizure prophylaxis)
pharmacologic treatments
Benzos - Oral syrup or IM Midazolam (sedative prior to surgery)
IV Propofol - sedative of choice for TBI, hypnotic
Osmotic diuretics - reduces cerebral edema, lowers ICP
Supporting TBI drugs Dobutamine & norepinephrine - improves CO
Antipyretics - prevents cerebral metabolism/edema
Corticosteroids/muscle relaxants/spasticity - for spinal cord injuries
QSEN safety alert: Phenobarbital 2 nurses should calculate the dosage
Immediate health history (what, when, direction of force)
LOC - duration, GCS
Response to tactile stimuli (if unconscious)
Pupillary response to light
Assessment of TBI patients
Corneal and gag reflexes
Motor function
Monitor ICP
Assess at frequent intervals
When a patient has sustained a severe head injury incompatible with life, the
patient is a potential organ donor.
Nurse assess for brain death (3 signs)
1. Coma
TBI organ donation
2. Absence of brainstem reflexes
3. Apnea
Diagnostic of brain death: Cerebral blood flow studies, electroencephalogram
(EEG), transcranial Doppler, and brainstem auditory-evoked potential
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1) Concussion
2) Contusion
3) Diffuse Axonal Injury
Types of brain injury 4) Hematomas (Intracranial Hemorrhage)
-Epidural Hematoma
-Subdural (acute/subacute and chronic)
-Intracerebral hemorrhage and hematoma
The most sensitive indicator of a lapse in neurologic functioning in patients with
Glasgow Coma Scale (GCS)
TBI and is often the earliest sign of acute change in ICP
*slowing of heart rate (bradycardia)
*increasing systolic blood pressure
*widening pulse pressure (Cushings reflex)
Signs of increasing ICP
As brain compression increases, respirations become rapid, blood pressure may
decrease, and pulse slows further
Why is a rapid increase in temperature Hyperthermia increases the metabolic demands of the brain and may indicate
unfavorable for a patient with TBI? brainstem damage—a poor prognostic sign
Monitoring fluid and electrolyte balance
Promote adequate nutrition
Prevent injury
Nursing management of TBI
Maintain body temp
Improving coping
Monitoring and managing potential complications
Elevate HOB
Neck in neutral alignment
Prevent Valsalva maneuver (stool softeners)
Maintain body temp
Controlling ICP in patients with severe
Administer oxygen
brain injury
Maintain fluid balance with NS
Avoid noxious stimuli (excessive suctioning, painful procedures)
Administer sedation
Maintain cerebral perfusion pressure of 50-70 mm Hg
Monitor airway and breathing
Maintain neutral head positioning
Monitor and educate patient on potential orthostatic hypotension
Maintain skin integrity
Nursing management of spinal cord injury
Prevent DVTs - take pressure off legs in bed
(SCI)
Relieve urinary retention / improve bowel function
Identify and treat autonomic dysreflexia
Early and adequate nutrition & fluids
Anticonvulsants for seizures
Breathing and strength of cough
Motor & sensory changes (ASIA classification)
Assessment of SCI
Urinary retention / overdistension
Hyperthermia (inability to perspire)
Promote breathing & airway clearance
Improve mobility (proper body alignment at all times, splints, trochanter rolls)
Prevent injuries
Interventions for SCI Maintain skin integrity
Maintain urinary elimination
Improve bowel function
Provide comfort measures (tongs, halo vest)
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Science Medicine Emergency Medicine
Med Surge Exam II Study Guide
5.0 (1 review)
Save
Students also studied
Flashcard sets Study guides
Care of the Client with Nutritional & ... Chapter 15: Clinical Judgment to Red... EMT Ch 29 Chapter Test EM
183 terms 16 terms 43 terms 74
m_horning_1 Preview nursingstudent8729 Preview Ashley_1737 Preview
Terms in this set (59)
Barbiturates - IV phenobarbitol (sedative, antiepileptic)
Traumatic brain injury (TBI)
Hydantoins - IV phenytoin (seizure prophylaxis)
pharmacologic treatments
Benzos - Oral syrup or IM Midazolam (sedative prior to surgery)
IV Propofol - sedative of choice for TBI, hypnotic
Osmotic diuretics - reduces cerebral edema, lowers ICP
Supporting TBI drugs Dobutamine & norepinephrine - improves CO
Antipyretics - prevents cerebral metabolism/edema
Corticosteroids/muscle relaxants/spasticity - for spinal cord injuries
QSEN safety alert: Phenobarbital 2 nurses should calculate the dosage
Immediate health history (what, when, direction of force)
LOC - duration, GCS
Response to tactile stimuli (if unconscious)
Pupillary response to light
Assessment of TBI patients
Corneal and gag reflexes
Motor function
Monitor ICP
Assess at frequent intervals
When a patient has sustained a severe head injury incompatible with life, the
patient is a potential organ donor.
Nurse assess for brain death (3 signs)
1. Coma
TBI organ donation
2. Absence of brainstem reflexes
3. Apnea
Diagnostic of brain death: Cerebral blood flow studies, electroencephalogram
(EEG), transcranial Doppler, and brainstem auditory-evoked potential
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of 7httpMed Surge Exam II Study Guidehttps://w
1) Concussion
2) Contusion
3) Diffuse Axonal Injury
Types of brain injury 4) Hematomas (Intracranial Hemorrhage)
-Epidural Hematoma
-Subdural (acute/subacute and chronic)
-Intracerebral hemorrhage and hematoma
The most sensitive indicator of a lapse in neurologic functioning in patients with
Glasgow Coma Scale (GCS)
TBI and is often the earliest sign of acute change in ICP
*slowing of heart rate (bradycardia)
*increasing systolic blood pressure
*widening pulse pressure (Cushings reflex)
Signs of increasing ICP
As brain compression increases, respirations become rapid, blood pressure may
decrease, and pulse slows further
Why is a rapid increase in temperature Hyperthermia increases the metabolic demands of the brain and may indicate
unfavorable for a patient with TBI? brainstem damage—a poor prognostic sign
Monitoring fluid and electrolyte balance
Promote adequate nutrition
Prevent injury
Nursing management of TBI
Maintain body temp
Improving coping
Monitoring and managing potential complications
Elevate HOB
Neck in neutral alignment
Prevent Valsalva maneuver (stool softeners)
Maintain body temp
Controlling ICP in patients with severe
Administer oxygen
brain injury
Maintain fluid balance with NS
Avoid noxious stimuli (excessive suctioning, painful procedures)
Administer sedation
Maintain cerebral perfusion pressure of 50-70 mm Hg
Monitor airway and breathing
Maintain neutral head positioning
Monitor and educate patient on potential orthostatic hypotension
Maintain skin integrity
Nursing management of spinal cord injury
Prevent DVTs - take pressure off legs in bed
(SCI)
Relieve urinary retention / improve bowel function
Identify and treat autonomic dysreflexia
Early and adequate nutrition & fluids
Anticonvulsants for seizures
Breathing and strength of cough
Motor & sensory changes (ASIA classification)
Assessment of SCI
Urinary retention / overdistension
Hyperthermia (inability to perspire)
Promote breathing & airway clearance
Improve mobility (proper body alignment at all times, splints, trochanter rolls)
Prevent injuries
Interventions for SCI Maintain skin integrity
Maintain urinary elimination
Improve bowel function
Provide comfort measures (tongs, halo vest)
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