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MEDSURG 2 NUR 265/265 Exam 3 Review FINAL Latest Docx $21.59   Add to cart

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MEDSURG 2 NUR 265/265 Exam 3 Review FINAL Latest Docx

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MEDSURG 2 NUR 265/265 Exam 3 Review FINAL Latest Docx

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  • February 9, 2023
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45: NEUROLOGIC PROBLEMS

MONITORING FOR INCREASED INTRACRANIAL PRESSURE
 Most at risk for increased ICP resulting from edema during the first 72 hr. after onset of a
stroke
 May have worsening neuro changes starting within 24-48 after their endovascular
procedure from increased ICP
 Assess these pt. Q 1-4 hr.

CHART 45-6 KEY FEATURES
 Decreased LOC (lethargy to coma)
 Behavior changes: restlessness, irritability, and confusion
 HA
 N/V (may be projectile)
 Change in speech pattern/slurred speech:
o Aphasia
 Change in sensorimotor status:
o Pupillary changes: dilated and nonreactive (“brown pupils”) or constricted and
nonreactive
o Cranial nerve dysfunction
o Ataxia
 Seizures (usually within first 24 hr. after stroke)
 Cushing’s triad:
o Severe HTN
o Widened pulse pressure
o Bradycardia
 Abnormal posturing:
o Decerebrate
o Decorticate


>> INTERVENTIONS
 For increased ICP experiencing a stroke:
o Elevate HOB – sitting them up is very important
o O2 therapy (for O2 < 94%)
o Maintain head in midline, neutral position – promotes venous drainage from the
brain

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, o Avoid sudden and acute hip or neck flexion during positioning
o Avoid the clustering of RN procedures – can elevate ICP even more
 Not for neuro pt.
o Hyperoxygenate before and after suctioning
o Provide airway management to prevent unnecessary suctioning and coughing
that can increase ICP
o Maintain quiet environment if pt. has a HA
o Keep the room lights low to accommodate and photophobia
o MT BP, heart rhythm, O2 sat, blood glucose, and body temp to prevent secondary
brain injury and promote positive outcomes after stroke
 MD usually like BP to be slightly elevated after a stroke (SBP = 140-150)
 CRITICAL RESCUE!! – Be alert for S/S of increased ICP in the head injury and report any
neuro deterioration to the MD or Rapid Response Team immediately!
o The 1st sign of increased ICP is a declining LOC




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,TRAUMATIC BRAIN INJURY (TBI)
>>> PATHO
 Can lead to temporary and permanent
impairment in cognition, mobility, sensory
perception, and psychosocial function
 Direct injury: blow directly to the head
 Indirect injury: force applied to another
body part with a rebound effect to the brain
 Sheared: rebound or rotated on the brain
stem
 Bruised: contusion of the brain
 Torn: laceration of the brain as it moves
across the inner surface of the cranial
 Acceleration injury: caused by n external force contacting the head, suddenly placing
the head in motion
 Deceleration injury: occurs when the moving head is suddenly stopped or hits a
stationary object


PRIMARY BRAIN INJURY
 Occurs at the time of injury -- Dives and hits head
 Can be focal or diffuse
o Focal: confined to a specific area of the brain and causes localized damage that
can often be detected with a CT scan or MRI
o Diffuse: damage throughout many areas of the brain
 Usually too small to detect with CT scan at first but cn worsen to a
detectable size
 MRI can see microscopic injuries
 Classified as open or closed
o Open: when the skull is fractured or pierced by a penetrating object
o Closed: the integrity of the skull stays intact
 Further defined as mild, moderate, or severe – usually determined by the Glasgow
coma scale immediately after resuscitation, presence of brain damage shown in CT scan
or MRI, estimation of force of the trauma, and S/S




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, SECONDARY BRAIN INJURY
 Any processes that occur after the initial injury and worsen or negatively influence pt.
outcomes.
o Increased swelling due to primary brain injury
 Result form physiologic, vascular, and biochemical events that are an extension of the
primary injury.
o Most common secondary injuries result from hypotension and hypoxia,
intracranial HTN, and cerebral edema.
o Damage to the brain tissue occurs primarily because the delivery of O2 and
glucose to the brain is interrupted from cerebral edema and increasing pressure.

> HYPOTENSION AND HYPOXIA
 Hypotension = MAP < 70
o r/t shock or clot formation
 Hypoxemia = PaO2 < 80
o r/t resp. failure, asphyxiation, or loss of airway and impaired ventilation
o leads to decreased cognition
 These restrict the flow of blood to vulnerable brain tissue

> INCREASED INTRACRANIAL PRESSURE
 Normal level of ICP = 10 – 15 mm Hg
 A sustained ICP of 20 is detrimental to the brain because neurons begin to die
 As a result of brain injury, the increase in the volume of one component must be
compensated for by a decrease in the volume of one of the other components
o Cerebral edema
 The brain can compensate for increased ICP by sending blood volume into the sinuses or
jugular veins.
 Increased ICP is the leading cause of death from head trauma in pt. who reach the
hospital alive
o Happens when the brain can no longer compensate for the increased ICP
o As ICP increases, cerebral perfusion decreases, leading to brain tissue ischemia
and edema
o Brain herniation syndrome: when the brain is forced downward thru the Forman
of Monro

> HEMORRHAGE
 Causes a brain hematoma (collection of blood) or clot, may occur at the primary injury
or arise later from vessel damage

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