NURSING MED SURG 3 Quizzes Medsurg

Traumatic Brain Injury – Glasgow Coma scale o Moderate: 9-12 o Greater than 13: There’s a minor head injury o Severe head injury: 8 and below  Glasgow coma scale o Priority assessment: LOC, PERRLA (tells us the level of brain injury)  If BP decreases on someone who has a brain injury o There will be an increased intracranial pressure.  Stroke o Right side of the brain controls: the left side of the brain.  Injury: may not recognize obvious objects or faces, may have spacial unawareness – don’t know the distances  Seizure disorder o Do not use the tongue depressor o Do guide them down on the floor, safety is an issue  PT has severe head injury, projectile vomiting, bp is high, HR high, temp high, what type of CNS injury is it? o Hemorrhagic stroke, sudden instant increase in vital signs meaning there was a vessel that ruptured.  A thrombus may cause an slow incremental increase.  Embolic stroke is when someone has a DVT, massaging the lower legs can cause it to travel. Slow increase.  Increased Intracranial Pressure o Restlessness is the first subtle sign