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Pressure inside the skull and thus in the brain tissue and cerebrospinal fluid
(CSF)
Measured in mm of mercury (mmHg)
Decerebrate posturing
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Occurs with damage at the level of the brainstem
-Posturing where neck is extended with jaw clenched; arms are pronated,
extended, and close to the sides; legs are extended straight out; more
ominous sign
Most severe.
, "De-cer-e-brate....is REALLY not great" (as a way to remember which one is
worse...decerebrate or decorticate.)
Sunsetting eyes
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A sign of increased intracranial pressure Able to see white
all above the iris
Anencephaly
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Defect in brain development resulting in small or missing brain
hemispheres, skull, and scalp
Majority of infants will be stillborn. If not, most anencephalic infants die
within hours to several days of birth
The infant is usually blind, deaf, unconscious, and unable to feel pain.
Nursing mgmt is supportive in nature and focuses on comfort measures for
the dying infant
Epileptic spasm such as infantile spasms
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, Type of epileptic spasm seen in infancy
Presents as symmetrical flexing or extending, in variant clinical patterns, of
the neck, arms, legs, and trunk
Majority of infants have some brain disorder before seizures begin.
Common diagnostic tests done for patient with seizures
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Serum glucose, electrolytes, and calcium - to rule out metabolic causes
LP - to rule out meningitis/encephalitis
Skull x-rays - to check for fracture/trauma
Head CT/MRI - to check for bleeds/tumors
EEGs - seizure type
Video EEGs - to see the child's behavior with seizure
The nurse is caring for an adolescent who says, "I'm sick of this. I wish I weren't
aliveanymore." What is the best response by the nurse?
A. "Have you thought about hurting yourself?"
B. "I often feel sad and sick of things."
C. "Do your parents know about this feeling?"
D. "Are you trying to escape your problems?"
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A. "Have you thought about hurting yourself?"