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nur 265 exam 3|80 Complete Questions and Answers
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nur 265 exam 3|80 CompleteQuestions and Answers
damage to the brain caused by an external force - -what is a tbi
-GCS of 13-15, difficulty to concentrate, (concussion), loss of consciousness
up to 30min - -what is a mild TBI classified as ?
-gcs of 9-12, loss of consciousness 30min-6hrs - -what is a moderate tbi
classified as?
-gcs 3-8, loss of consciousness more than 6hrs - -what is a severe tbi
classified as?
-open-skull is fractured
closed-blunt force trauma, integrity of skull isnt compromised
closed is worse - -difference between open and closed tbi
-Brain Hernitation-cheyne stokes breathing, hemodynamic instability, fixed
and non-reactive pupils - -what is the complication of a tbi and IICP and what
is its symptoms?
-1. mannitol-via iv filter, used until serum osmolarity reaches 310-320
2. furosomide
3.fentanyl- decrease pain and restlessness
4. proprofol and midazalam-sedation
5.lidocaine- to surpress cough reflex - -what are the medications used for a
TBI?
-used in a TBI
pt core temp is reduced to 89.6-93.2 for 24-48hrs post primary injury,
decreases cellular demands - -what is therapuetic hypothermia ?
-1.assess ABC's
2.implement spine precautions
3.)vital signs
4.)neuro assessment
*report any GCS point change of 2 or more - -assessment for TBI
--pt supine
-spine and head in neutral midline position
-bed rest
-NO neck of hip flexion
, -NO thoracic/lumbar flexion
-manual control of cervical spine when C collar is removed
-log roll - -what is included in spine precautions?
--vitals Q1-2hrs
-if intubated provide 100%o2 before and after every suction
-maintain Pao2 80-100
-AVOID hyperventilation in the first 24hrs
-implement seizure precautions
-maintain hazard free environment
-reorient pt to person, place and time
-always re introduce yourself when you go in pt room
-keep explanations short and simple
- collab with rehab for cognitive rehab - -nursing interventions for TBI
--acetaminophen Q4hrs as needed for headache
-avoid sedatives and alcohol for at least 24 post TBI
-AVOID strenuous activity for at least 48 hrs
-keep follow up appts
-call 911 if :
-seizure -increased weakness -servere of worsening HA -slurred speech -
blurred vision -clear drainage from ears or nose -unequal pupils - increased
sleepiness - -pt educations for TBI (mild)
-- dazed and confused
-inability to concentrate
-amnesia
-mental fog
-irritable
-N/V
-gait changes
-visual changes
dizziness
-sleeping more or less
-trouble falling asleep - -symptoms of mild TBI
-10-15mm hg - -what is the normal range for ICP?
-change in LOC - -earliest sign of IICP
--loc changes
-servere HA
-aphasia
-vomiting
-atazia
-seixures
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