Certified Emergency Nurse (CEN) Exam Review Jeff Solheim
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Definition: Cushing’s Triad – Abnormal set of vital signs often associated with
advanced or increased intracranial pressure. Includes:
Profound bradycardia
Abnormal respirations
Increased systolic pressure (w...
At the completion of this section, the learner will be able to:
Differentiate between early and late signs of increased intracranial p ressure
Discuss care of the patient with a basilar sku ll fracture
Define autonomic dysreflexia
Recognize medicat ions used in the treatment of seizu res
Verbalize d ischarge instructions that should be provided to patients with Myasthenia Grav is
The CEN exam contains fifteen questions on neurological emergencies which i nvol ve the followi ng topics:
Increased intracranial pressure (ICP)
Cran ial Vau lt consists of three constituents: brain, cerebral spinal fluid (CSF) and blood.
Normal ICP: 0 - 15 mm Hg
Elevated ICP: > 20 mm Hg
Extremely high ICP may lead to herniation of the brain.
Clin ical Manifestations of increased intracranial p ressure:
EARLY S IGNS (Increased ICP) LATE S IGNS (Herniation)
Level of More stimu lation required to get Arousable only with deep
Consciousness same response pain or unarousable
Pupils Sluggish response to light Fixed or d ilated
Loss of one or mo re grades on the
Motor Function Posturing or no response
strength scale
Vital Signs Tachycardia, hypertensive swings Cushing’s response
Definiti on: Cushing’s Triad – Abnormal set of vital signs often associated with
advanced or increased intracranial pressure. Includes:
Profound bradycardia
Abnormal respirations
Increased systolic pressure (widened pulse pressure)
Treat ment
Reduce ICP by reducing the constituents of the skull:
Brain Blood CSF Flui d
Patient position
Maintain normothermia
Diuret ics Surgical decompression
Prevent/ treat seizures
Hypertonic solutions CSF drainage catheter
Reduce noxious stimuli
Suctioning
Problem Sympto ms Treat ment
As per ICP for head injury
Obstructed Signs of ICP (irritability, headache, neck pain, vo miting, bulg ing
shunt fontanels, new seizures, change in behavior.) Flushing of the shunt.
Signs of obstruction
Local wound problems Antibiotics
Infected
Unexplained fevers Sepsis protocols
shunt
Redness, edema and tenderness along skin over the shunt.
Signs of peritonitis (if shunt terminates in the abdomen.)
Depressed fontanels Replacement of shunt
Over- Overlapping of sku ll bones Supportive therapy (oxygen, treat
drainage headache when upright, when supine seizures and bleeds as per protocols.
Subdural hemato mas Suction PRN
o Glasgow Co ma Scale
Best Motor Response Best Verbal Response Eye Opening
Obeys simple co mmands 6 Oriented 5 Spontaneously 4
Localizes noxious stimulus 5 Confused 4 To speech 3
Verbalizes, inappropriate
Flexion withdrawal 4 3 To noxious stimulus 2
words
Abnormal flexion 3 Vocalizes – moans/groans 2 No eye opening 1
Abnormal extension 2 No verbal response 1
No motor response 1
Eyes and pupils
Size – pupils should be with in 1 mm in size o f one another.
Anisocoria: pupils that are more
Shape – pupils are normally round. Irregularly shaped pupils, especially oval, than one millimeter different in size.
indicate dysfunction or pressure on oculomotor nerve III. Anisocoria occurs normally in as
Degree of reactivity – both pupils should rapidly constrict when light is shone many as 20 – 25% of patients, and
into one of them. is more co mmon with age.
Best motor response
Assess motor and sensory function or weakness, loss of movement or altered sensation to any part of the body
Assess for pronator drift in the conscious, cooperative patient: ask the patient to close his or her eyes, and extend the
arms out directly in front of them, ho lding this position for 30 seconds. If one arm drifts downward ahead of the other, it
is an indicator of weakness to that side of the body.
Deficits fro m the neck up affect the same side - paresis (such as hemiparesis) indicates
as the brain lesion (ipsilateral) and deficits weakness to an area of the body.
fro m the neck down affect the opposite side as -plegia (such as paraplegia) indicates
the brain lesion (contralateral) paralysis to an area of the body.
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