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NUR2115 Exam 3 latest/ 230 Questions and Answers/ verified and Graded A+
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NUR2115 Exam 3 latest/ 230 Questions andAnswers/ verified and Graded A+
Cerebral Perfusion Pressure (CPP) - -MAP-ICP
-Normal CPP - -80-100 mmHg
-Mean Arterial Pressure (MAP) - -(SBP + 2DBP)/3
-Normal MAP - ->70-80 mmHG
-Normal Intracranial pressure - -5-15 mmHg
-Intracranial components - -10% blood, 10% CSF, 80% Brain
-Monro-Kellie Hypothesis - -If the volume of any of the intracranial components
changes, it must be compensated for by another component. The total volume of the
intracranial compartment must remain fixed.
-Neurological exam components - -LOC
Pupillary function
Motor function
Respiratory function
Vital signs
-Arousal - -Evaluates lowest level of consciousness
-Alert - -Patient responds to gently calling name
-Lethargic - -Patient must be shouted at to gain attention
-Obtunded - -Patient responds to noxious, painful stimuli such as sternal rub or
trapezius pinch
-Comatose - -Patient responds to NO stimuli
-Awareness - -Evaluates higher level of consciousness
-Orientation - -Determines level of awareness. Evaluate orientation to person, place,
time, and situation
-Motor response - -Use noxious peripheral stimulation if needed to elicit a response
-Spontaneous response - -Obeys commands
-Localizes pain response - -Opposite extremity crosses over midline to remove stimulus
,-Withdrawal response - -Patient presents normal flexion to avoid stimulus
-Decorticate response - -Patient presents abnormal flexion in response to stimulus
-Decerebrate response - -Patient presents abnormal extension in response to noxious
stimuli
-Flaccid response - -Patient does not respond at all to stimuli
-PERRLA - -Pupils Equal Round Reactive to Light and Accommodating
-Pupils oval - -Pupillary sign of increased ICP
-Pupils constricted - -Pupillary sign of brain stem compression or narcotic use
-Pupils dilated - -Indicates ICP = 25-30 mmHG (normal 5-15)
-Pupils unequal - -Indicates impending brain herniation
-Oculocephalic reflex - -Doll's eyes. Normal eye reflex. Patient's eyes move to opposite
side when head is turned
-Abnormal oculocephalic reflex - -Patient's eyes move to same side when head is
turned
-Absent oculocephalic reflex - -Eyes remain fixed when head is turned. Shows
significant brain stem injury
-Central fever - -Due to hypothalamic damage. Will not respond to antipyretics and
patient displays no sweating. Responds to cooling blankets.
-Cushing's Triad - -Bradycardia, Systolic HTN, Widening pulse pressure
-Cushing's Reflex - -Bradycardia, Systolic HTN, Bradypnea. Late sign of increased ICP
-Glasgow Coma Scale - -Most widely used tool to evaluate LOC. Does not provide a
complete neural exam, gives information about LOC only based on eye opening, verbal
response, and motor response. Grades from 1-5. Best score 15. Worst score 3.
-GCS <8 - -Indicates coma
-S/S of increased ICP - -Decreased LOC
Cushing's reflex
Posturing (decreased brain stem reflexes)
Unequal pupils/decreased reaction to light
Altered breathing patterns
, Headache
Projectile vomiting
-ICP Monitoring sites - -Subdural
Epidural
Parenchymal
Intraventricular
-Positions to avoid - -Trendelenburg, prone, hip flexion, neck angulation
-Activities to avoid - -PEEP >20, Coughing, Suctioning, Valsalva maneuver
-Hyperventilation - -Keep PCO2 between 25-30 (low) to induce respiratory alkalosis
and combat cerebral acidosis
-Therapeutic hypothermia - -Reducing patient temperature to between 32-35 C to treat
anoxic brain injury or TBI
-Hypothermia phases - -Induction, Maintenance, Rewarming
-Prophylactic anticonvulsants - -Phenytoin/Phenobarbitol give to prevent post-
traumatic seizures in TBI patients.
-Lorazepam - -Seizure medication given to TBI patients to treat breakthrough seizures
-Hypertension with TBI - -Maintain BP in high normal range. Treat with
antihypertensives but avoid vasodilators unless given concomitantly with beta-blockers
-Minimum SBP - -SBP must be maintained >90 mmHG. Used crystalloids, colloids, or
ionotropic agents to maintain if necessary
-Dopamine, Levophed - -Positive ionotropic agents given to maintain SBP post TBI
-Pain control - -Give TBI patients opioids such as morphine or fentanyl to control pain
and reduce metabolic demands
-Anxiety control - -Give TBI Benzodiazepines such as Ativan or Versed
-IV Hypnotics - -Use propofol to reduce aggitation in TBI patients to reduce metabolic
demands
-NBMA - -Neuromuscular blocking agents such as Vecuronium or Atracurium given to
TBI patients to reduce aggitation and reduce metabolic demands
-Shivering control - -Give TBI patients Demerol or thorazine to treat/prevent shivering
in TBI patients. Especially those undergoing therapeutic hypothermia
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