NUR 335 Quiz 4 Test Questions and Detailed Answers
6 views 0 purchase
Course
NUR 335
Institution
NUR 335
Increased Intracranial Pressure (ICP) Higher than normal pressure within the cranium Destroys healthy brain tissue and alters mental function
Causes Tumors or lesions Accumulation of fluid within the ventricular system Bleeding or trauma Edematous brain tissue Trauma
Complications Brain death Car...
NUR 335 Quiz 4 Test Questions and
Detailed Answers
Increased Intracranial Pressure (ICP) ✅Higher than normal pressure within the
cranium
Destroys healthy brain tissue and alters mental function
Causes
Tumors or lesions
Accumulation of fluid within the ventricular system
Bleeding or trauma
Edematous brain tissue
Trauma
Complications
Brain death
Cardiac arrest
Respiratory insufficiency or arrest
Pathophysiology
Rigid skull allows little room for expansion
Brain compensates for increases in ICP limits blood flow to head
displaces CSF into the spinal canal
increases absorption or decreases production of CSF by withdrawing water from the
brain tissue into the blood and excreting it via the kidneys
Age Specific Assessment Findings
Infants
Bulging fontanels without normal pulsations
Irritability
Shrieking, high-pitched cry
Increased head circumference
Decreased LOC
Altered feeding pattern
Distended scalp veins
Top Three Signs of ICP in Infant
Bulging fontanels without normal pulsations
Shrieking high-pitched cry
Increased head circumference
Children
Vomiting with or without nausea
,Headache
Diplopia
Seizures
Top three signs of ICP in children
Vomiting
Headache
seizures
Other signs common to any age
Lack of interest
Decreased motor activity
Increased sleep
Weight loss
Lethargy that progresses to drowsiness
Increased BP, decrease HR, decreased RR
Late signs
Diminished response to painful stimuli
Altered pupil size and reactivity
Posturing; Decorticate, decerebrate
Cheyne-stokes respirations
Papilledema
Management
Subdural tap
Ventricular tap
Hyperventilation via mechanical ventilation to reduce CO2
Nursing Interventions
Monitor neuro status including LOC and pupil size and reactivity
Monitor ICP; report deviations, maintain patency and calibration of
Cerebral Palsy ✅Non-progressive neuromuscular disorder of varying degree
Damaged area of brain that controls motor function
Types
Spastic
, Dyskinetic or athetoid
Ataxic
Mixed
Causes
Anoxia before, during or after birth
Infection
Trauma
Assessment findings (all types)
Delayed gross motor development
Abnormal motor and coordination, may be early ie; poor sucking, feeding difficulty
Abnormal posture at rest or when changing position
Altered muscle tone
Increased or decreased resistance passive ROM
Opisthotonic postures (exaggerated arch of the back)
Spasticity of the hip muscles and lower extremities
Abnormal reflexes
Persistent primitive reflexes
Other disabilities
Mental retardation of varying degrees
Seizures
Attention deficit disorder
Sensory deficits
Vision (strabismus)
Hearing
speech
Findings per type
Ataxic
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller twishfrancis. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.