NURS 265 Exam 3 Review FINAL.

NEUROLOGIC PROBLEMS MONITORING FOR INCREASED INTRACRANIAL PRESSURE  Most at risk for increased ICP resulting from edema during the first 72 hr. after onset of a stroke  May have worsening neuro changes starting within 24-48 after their endovascular procedure from increased ICP  Assess these pt. Q 1-4 hr. CHART 45-6 KEY FEATURES  Decreased LOC (lethargy to coma)  Behavior changes: restlessness, irritability, and confusion  HA  N/V (may be projectile)  Change in speech pattern/slurred speech: o Aphasia  Change in sensorimotor status: o Pupillary changes: dilated and nonreactive (“brown pupils”) or constricted and nonreactive o Cranial nerve dysfunction o Ataxia  Seizures (usually within first 24 hr. after stroke)  Cushing’s triad: o Severe HTN o Widened pulse pressure o Bradycardia  Abnormal posturing: o Decerebrate o Decorticate INTERVENTIONS  For increased ICP experiencing a stroke: o Elevate HOB – sitting them up is very important o O2 therapy (for O2 94%) o Maintain head in midline, neutral position – promotes venous drainage from the brain 1 o Avoid sudden and acute hip or neck flexion during positioning o Avoid the clustering of RN procedures – can elevate ICP even more  Not for neuro pt. o Hyperoxygenate before and after suctioning o Provide airway management to prevent unnecessary suctioning and coughing that can increase ICP o Maintain quiet environment if pt. has a HA o Keep the room lights low to accommodate and photophobia o MT BP, heart rhythm, O2 sat, blood glucose, and body temp to prevent secondary brain injury and promote positive outcomes after stroke  MD usually like BP to be slightly elevated after a stroke (SBP = 140-150)  CRITICAL RESCUE!! – Be alert for S/S of increased ICP in the head injury and report any neuro deterioration to the MD or Rapid Response Team immediately! o The 1st sign of increased ICP is a declining LOC 2 TRAUMATIC BRAIN INJURY (TBI) PATHO  Can lead to temporary and permanent impairment in cognition, mobility, sensory perception, and psychosocial function  Direct injury: blow directly to the head  Indirect injury: force applied to another body part with a rebound effect to the brain  Sheared: rebound or rotated on the brain stem  Bruised: contusion of the brain  Torn: laceration of the brain as it moves across the inner surface of the cranial  Acceleration injury: caused by n external force contacting the head, suddenly placing the head in motion  Deceleration injury: occurs when the moving head is suddenly stopped or hits a stationary object  PRIMARY BRAIN INJURY  Occurs at the time of injury -- Dives and hits head  Can be focal or diffuse o Focal: confined to a specific area of the brain and causes localized damage that can often be detected with a CT scan or MRI o Diffuse: damage throughout many areas of the brain  Usually too small to detect with CT scan at first but cn worsen to a detectable size  MRI can see microscopic injuries  Classified as open or closed o Open: when the skull is fractured or pierced by a penetrating object o Closed: the integrity of the skull stays intact  Further defined as mild, moderate, or severe – usually determined by the Glasgow coma scale immediately after resuscitation, presence