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NURS 440 Unit 4 Intracranial Regulation – Questions With Complete Solutions

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NURS 440 Unit 4 Intracranial Regulation – Questions With Complete Solutions

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Terms in this set (125)



Perfusion ICP When disrupted:
infarct - blockage of blood vessel from plaque or tumor
inter cranial hemorrhage - TBO
severe hypertension


Neurotransmission ICP When disrupted:
seizures
degenerative diseases


Pathology ICP When disrupted:
infection
alzheimer's
huntington's


When does a child's head become fixed? age 5


no room to expand when swells leading to death of tissue


Physiologic consequence of the blood brain Can become compromised and lead to infection
barrier


Physiologic process of the meninges Protective layers


Intracranial problems are usually related to a specific layer


Physiologic consequences of glucose Hypoglycemia episodes, can't function, brain death


Physiologic processes of auto regulation Blood flow


Physiologic consequences of Decrease in CO2 causes vasoconstriction
hyperventilation Decrease in blood volume and inter cranial pressure
increase risk of ischemia within first 20 hours of injury,
hyperventilate after this time


Why should we detect and prevent cerebral Leads to cerebral edema, increased intracranial pressure,
edema? decreased perfusion, decreased oxygenation, cellular death

, What is the difference cerebral edema and Edema - swelling leads to intracranial pressure
increased intracranial pressure? Intracranial pressure - finite volume of space


What are early symptoms of IICP in infants? Bulging fontanels
Increased head circumference
Lethargic
Poor feeding/weigh gain
Irritable (shrill cry)
Separation at sutures


What are early symptoms of IICP in adults? Change in LOC
C/O headache
Confusion
Shallow breathing
Nausea without vomiting or vomiting without nausea
Hypertension


What are the components of Cushing's Increase in BP
triad? Decrease in HR
Decrease in respiration
Sign of eminent death


What are important assessment findings Hypercapnia
related to cerebral perfusion pressure? Hypoxia
Hypoventilation leads to increased CO2


What are the components of the Glasgow Eye opening
Coma scale for adults? Verbal
Motor


What is PERRLA? Pupils equal round reactive to light and accommodating


CN 1 Olfactory


Olfactory Nerve Assessment Close eyes, smell, name item


CN II Optic


Optic Nerve Assessment Stand arm's length away, cover eye, nurse covered eye on
same side, stare at nurse's uncovered eye, move other hand in
field holding up fingers


Vision chart - cover one eye at a time


CN III Oculomotor


Oculomotor Nerve Assessment Assess for involuntary shaking of eye (nystagmus) - hold pen
light a foot away from the face, move in 6 cardinal fields of
gaze


Reaction to light - dim light, shine light on wow from the side,
assess constriction direct and indirect


PERRLA


CN IV Trochlear


Trochlear Nerve Assessment Stare at object far off, follow pen light as it comes closer to
the nose

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