Exam 3 Study Material NUR 265 - A+ Graded Solutions

Exam 3 Study Material NUR 265 - A+ Graded Solutions damage to the brain caused by an external force - answer - what is a tbi GCS of 13-15, difficulty to concentrate, (concussion), loss of consciousness up to 30min - answer - what is a mild TBI classified as ? gcs of 9-12, loss of consciousness 30min-6hrs - answer - what is a moderate tbi classified as? gcs 3-8, loss of consciousness more than 6hrs - answer - what is a severe tbi classified as? open-skull is fractured closed-blunt force trauma, integrity of skull isnt compromised closed is worse - answer - difference between open and closed tbi Brain Hernitation-cheyne stokes breathing, hemodynamic instability, fixed and non-reactive pupils - answer - what is the complication of a tbi and IICP and what is its symptoms? 1. mannitol-via iv filter, used until serum osmolarity reaches 310-320 2. furosomide nyl- decrease pain and restlessness 4. proprofol and midazalam-sedation aine- to surpress cough reflex - answer - what are the medications used for a TBI? used in a TBI pt core temp is reduced to 89.6-93.2 for 24-48hrs post primary injury, decreases cellular demands - answer - what is therapuetic hypothermia ? s ABC's ment spine precautions 3.)vital signs 4.)neuro assessment *report any GCS point change of 2 or more - answer - assessment for TBI -pt supine -spine and head in neutral midline position -bed rest -NO neck of hip flexion -NO thoracic/lumbar flexion -manual control of cervical spine when C collar is removed -log roll - answer - what is included in spine precautions? -vitals Q1-2hrs -if intubated provide 100%o2 before and after every suction -maintain Pao2 80-100 -AVOID hyperventilation in the first 24hrs -implement seizure precautions -maintain hazard free environment -reorient pt to person, place and time -always re introduce yourself when you go in pt room -keep explanations short and simple - collab with rehab for cognitive rehab - answer - nursing interventions for TBI -acetaminophen Q4hrs as needed for headache -avoid sedatives and alcohol for at least 24 post TBI -AVOID strenuous activity for at least 48 hrs -keep follow up appts -call 911 if : -seizure -increased weakness -servere of worsening HA -slurred speech -blurred vision -clear drainage from ears or nose -unequal pupils - increased sleepiness - answer - pt educations for TBI (mild) - dazed and confused -inability to concentrate -amnesia -mental fog -irritable -N/V -gait changes -visual changes dizziness -sleeping more or less -trouble falling asleep - answer - symptoms of mild TBI 10-15mm hg - answer - what is the normal range for ICP? change in LOC - answer - earliest sign of IICP -loc changes -servere HA -aphasia -vomiting -atazia -seixures -irritibilty -restlessness -confusion -positive babinski reflex -abnormal posturing (late sign) -pupillary changes (late sign ) (2mm change in either direction notify MD) -cushings triad - answer - s/s of IICP severe hypertension widened pulse pressure bradycardia - answer - what is the cushings triad? -mannitol -furosemide -oxygenation (hyperventilate to decrease CO2) -barbiturates/sedation -intraventricular drain system - answer - medical tx for IICP 1. Elevate HOB- per md order but standard is 30 degress -provide O2 for sat less than 95 -maintain head and neck in midline postioin - AVOID neck and hip flexion -log roll pt -AVOID cluster care -preform GCS assessment -hyperoxygenate pt before and after suction - preform suction ONLY when neccesary, avoid longer than 10sec - provide airway management to prevent cough and suction needs -maintain quiet and dim lit environment -closely monitor VS, pupils and LOC - answer - nursing interventions for IICP infection and inflammation of the meninges - answer - what is meningitis? bacterial menningioccial - answer - what is the most dangerous form of meningitis? 1. decrease LOC -nuchal regidity -kernigs sign: start with pt supine, flex theigh at 90 degree angle, exte