NUR 445: Exam 3 Review
What is intracranial pressure?
When pressure inside the skull dramatically increases.
Name some factors that can increase ICP.
- Hypoxia
- Hypercapnia
- Hyperthermia
- TBI's
- Hemorrhage
What should the nurse ask clients with ICP?
- When was their last bowel movement
- Any noticed signs or symptoms of infection
- Any noise drainage
- How is their intake and output?
Name one of the earliest signs of ICP.
Mental status change- Restless, agitated, confused.
Name five other early signs of ICP.
- Double vision, swelling of the optic nerve, dilated pupils, unequal
- Positive Babinski reflex
- Decorticate or decerebrate posturing
- Seizure, headache, vomiting WITHOUT nausea
- Deterioration of motor function
Describe decerebrate posture.
An abnormal body posture that involves the arms and legs being held straight out, the toes
being pointed downward, and the head and neck being arched backward.
, What are three late signs of intracranial pressure?
- Irregular breathing: Cheyne's stokes
- Unconscious
- Cushing Triad: Increase in BP and decrease in HR, RR
Describe pneumothorax.
Air enters the pleural space, disrupts negative pressure, and causes the lung to collapse.
Note: This is also known as collapsed lung.
What are three common causes of a pneumothorax?
- Blunt force trauma: Gunshot wound, stabbing.
- Medical procedures: Central line placement, thoracentesis.
- Mechanical ventilation: Too much PEEP
What are six signs of pneumothorax?
- Sudden chest pain
- Cyanosis
- Unequal chest expansion
- Use of accessory muscles
- Dyspnea: Low O2 and BP. High HR
- Absent breath sounds
What is the difference between open and closed pneumothorax?
- Open: Penetrating thoracic injury that causes air to enter from the outside in.
- Closed: Air enters the pleural space without an outside wound.
Describe a tension pneumothorax.
Worsening of a pneumothorax where air accumulates so much and cannot escape-- Increased
intrathoracic pressure.
What is intracranial pressure?
When pressure inside the skull dramatically increases.
Name some factors that can increase ICP.
- Hypoxia
- Hypercapnia
- Hyperthermia
- TBI's
- Hemorrhage
What should the nurse ask clients with ICP?
- When was their last bowel movement
- Any noticed signs or symptoms of infection
- Any noise drainage
- How is their intake and output?
Name one of the earliest signs of ICP.
Mental status change- Restless, agitated, confused.
Name five other early signs of ICP.
- Double vision, swelling of the optic nerve, dilated pupils, unequal
- Positive Babinski reflex
- Decorticate or decerebrate posturing
- Seizure, headache, vomiting WITHOUT nausea
- Deterioration of motor function
Describe decerebrate posture.
An abnormal body posture that involves the arms and legs being held straight out, the toes
being pointed downward, and the head and neck being arched backward.
, What are three late signs of intracranial pressure?
- Irregular breathing: Cheyne's stokes
- Unconscious
- Cushing Triad: Increase in BP and decrease in HR, RR
Describe pneumothorax.
Air enters the pleural space, disrupts negative pressure, and causes the lung to collapse.
Note: This is also known as collapsed lung.
What are three common causes of a pneumothorax?
- Blunt force trauma: Gunshot wound, stabbing.
- Medical procedures: Central line placement, thoracentesis.
- Mechanical ventilation: Too much PEEP
What are six signs of pneumothorax?
- Sudden chest pain
- Cyanosis
- Unequal chest expansion
- Use of accessory muscles
- Dyspnea: Low O2 and BP. High HR
- Absent breath sounds
What is the difference between open and closed pneumothorax?
- Open: Penetrating thoracic injury that causes air to enter from the outside in.
- Closed: Air enters the pleural space without an outside wound.
Describe a tension pneumothorax.
Worsening of a pneumothorax where air accumulates so much and cannot escape-- Increased
intrathoracic pressure.
