NSG 430 FINAL STUDY GUIDE
1. Manifestations of Increased Intracranial Pressure: Hypertension, Bradycar-dia, Fixed
pupils
**decreased LOC is first sign**
2. Compressions of CN 3: Ipsilateral (same side) dilation
-may have sluggish pupil response to light or inability to move eye if caused bymidline shift
3. Cushing's triad: Systolic HTN (widened pulse pressure)Bradycardia (full and bounding)
Irregular Respirations
4. decorate posturing: Flexed upper extremities (pulled in)
5. Decerebate posture: Arms extended stiff (worse prognosis)
6. ventriculostomy: a catheter placed in one of the lateral ventricles of the brainto measure
intracranial pressure and allow for drainage of fluid
*Tandsducer level with foramen Moro (Tragus)
7. Manitol: osmotic diuretic
-Decreases ICP
8. IV fluids for decreasing ICP: Hypertonic saline (3% NaCl)
9. Glasgow Coma Scale: 3-15Below 8 is a coma
Eyes open Verbal responseMotor response
10. Dolls eye reflex: turning the head, pupils should move to the opposite side.
11. oculovestibular reflex: When ice cold water is injected into ear canal the eyesdeviate
toward the irrigated ear if brainstem is intact
12. Suctioning with ICP: No more than 10 seconds at a time and give high doseoxygen right
before
No more than 2 passes
13. Body position for Increased ICP: Head midline with no neck flexation
- Elevate head to no more than 30
14. Raccoon eyes, battles sign: signs of basilar skull fracture
15. halo sign: blood stain surrounded by a yellowish stain; highly suggestive of a
cerebrospinal fluid leak
16. diffuse axonal injury: damage to nerve cells in the connecting fibers of thebrain
, - appears 12-24 hours after injury
*POOR PROGNOSIS*
17. epidural hematoma: Bleeding between dura and inner surface of skull
18. Subdural hematoma: Bleed between dura mater and arachnoid layer
19. Bacterial Meningitis: inflammation of the meninges
20. Manifestations of bacterial meningitis: Nuchal rigidity
*stiff neck*nausea vomiting fever
chills
Petichea on trunk
21. Care for meningitis: -seizure precautions
-dark room and cover eyes for photophobia
-Deceease environment stimuli to help them from being scared
-GET RID OF FEVER (increases ICP) but not too rapid to cause shivering
22. spinal shock: After acute spinal cord injury
-Loss of DTR, Loss of sensation, Flacid paralysis below injury
-can last days to weeks
23. neurogenic shock: Occurs for T6 or higher injury
-Peripheral vasodilation, venous pooling, decreased Cardiac output
-hypotension, bradycardia, temp changes
*GIVE FLUIDS TO PREVENT HYPOTENSION
24. Anterior cord syndrome: damage to the anterior spinal artery usually resultingfrom injury
causing acute compression of the anterior portion of the spinal cord; manifestations include
motor paralysis and loss of pain and temperature sensationbelow the level of injury.
25. Brown-Sequard Syndrome: Damage to half of spinal cord
Loss of pain and temperature sensation on contralateral side (opposite side) of bodyLoss of
motor and discriminatory touch on ipsilateral (same side) side of body.
26. caude equina syndrome: Damage to lumbar and sacral nerve root
- assymetric distal weakness, flaccid paralysis of lower extremities, flaccid boweland bladder,
severe asymmetric pain
27. Central Cord Syndrome: Damage to central spinal cord
-motor weakness and altered sensation in UPPER extremities, burning pain inUPPER
1. Manifestations of Increased Intracranial Pressure: Hypertension, Bradycar-dia, Fixed
pupils
**decreased LOC is first sign**
2. Compressions of CN 3: Ipsilateral (same side) dilation
-may have sluggish pupil response to light or inability to move eye if caused bymidline shift
3. Cushing's triad: Systolic HTN (widened pulse pressure)Bradycardia (full and bounding)
Irregular Respirations
4. decorate posturing: Flexed upper extremities (pulled in)
5. Decerebate posture: Arms extended stiff (worse prognosis)
6. ventriculostomy: a catheter placed in one of the lateral ventricles of the brainto measure
intracranial pressure and allow for drainage of fluid
*Tandsducer level with foramen Moro (Tragus)
7. Manitol: osmotic diuretic
-Decreases ICP
8. IV fluids for decreasing ICP: Hypertonic saline (3% NaCl)
9. Glasgow Coma Scale: 3-15Below 8 is a coma
Eyes open Verbal responseMotor response
10. Dolls eye reflex: turning the head, pupils should move to the opposite side.
11. oculovestibular reflex: When ice cold water is injected into ear canal the eyesdeviate
toward the irrigated ear if brainstem is intact
12. Suctioning with ICP: No more than 10 seconds at a time and give high doseoxygen right
before
No more than 2 passes
13. Body position for Increased ICP: Head midline with no neck flexation
- Elevate head to no more than 30
14. Raccoon eyes, battles sign: signs of basilar skull fracture
15. halo sign: blood stain surrounded by a yellowish stain; highly suggestive of a
cerebrospinal fluid leak
16. diffuse axonal injury: damage to nerve cells in the connecting fibers of thebrain
, - appears 12-24 hours after injury
*POOR PROGNOSIS*
17. epidural hematoma: Bleeding between dura and inner surface of skull
18. Subdural hematoma: Bleed between dura mater and arachnoid layer
19. Bacterial Meningitis: inflammation of the meninges
20. Manifestations of bacterial meningitis: Nuchal rigidity
*stiff neck*nausea vomiting fever
chills
Petichea on trunk
21. Care for meningitis: -seizure precautions
-dark room and cover eyes for photophobia
-Deceease environment stimuli to help them from being scared
-GET RID OF FEVER (increases ICP) but not too rapid to cause shivering
22. spinal shock: After acute spinal cord injury
-Loss of DTR, Loss of sensation, Flacid paralysis below injury
-can last days to weeks
23. neurogenic shock: Occurs for T6 or higher injury
-Peripheral vasodilation, venous pooling, decreased Cardiac output
-hypotension, bradycardia, temp changes
*GIVE FLUIDS TO PREVENT HYPOTENSION
24. Anterior cord syndrome: damage to the anterior spinal artery usually resultingfrom injury
causing acute compression of the anterior portion of the spinal cord; manifestations include
motor paralysis and loss of pain and temperature sensationbelow the level of injury.
25. Brown-Sequard Syndrome: Damage to half of spinal cord
Loss of pain and temperature sensation on contralateral side (opposite side) of bodyLoss of
motor and discriminatory touch on ipsilateral (same side) side of body.
26. caude equina syndrome: Damage to lumbar and sacral nerve root
- assymetric distal weakness, flaccid paralysis of lower extremities, flaccid boweland bladder,
severe asymmetric pain
27. Central Cord Syndrome: Damage to central spinal cord
-motor weakness and altered sensation in UPPER extremities, burning pain inUPPER
