Acute intracranial disorders + Spinal cord trauma - red Flashcards
Increased ICP may significantly reduce cerebral blood flow leading to this CLASSIC sign.
This is a grave sign of ICP.
widening pulse pressure
Cushing’s Triad - bradycardia, HTN, bradypnea
What are the differenes between cardiogenic shock and IICP?
IICP
- HTN, bradycardia, bradypnea, widening pulse pressure
Cardiogenic shock:
- hypotension, tachycardia, tachypnea, narrowing pulse pressure
IICP:
- Early signs and symptoms?
Late signs and symptoms?
Early:
- irritability and restlessness
- Nuchal rigidity
Late:
- widening pulse pressure
most important nursing intervention to change in LOC?
Protect the airway
Decorticate posturing indicates a lesion in this area
mesencephalic or midbrain region
Decerebrate posturing indicates compression here.
Brainstem
Management of ICP:
- Most important drug for managing cerebral edema
Steroids (dexamethasone)
What is important to do for nursing interventions geared toward ICP in severe brain injuries?
Spread out nursing interventions (keep stimulation low)
Concussions can still happen if…
You do not lose consciousness
Symptoms of a concussion - most important one?
Sensitivity to light or noise
Important piece of teaching regarding concussions?
When in doubt, get checked out? (doubles for STI teaching)
Most important clinical manifestation of brain tumours?
Headache - usually dull and constant, worse at night
Most important treatment for brain tumours?
Dexamethasone (corticosteroid)
Bacterial meningitis?
- What is it? (not definition)
- Classic sign?
Medical emergency
Nuchal rigidity
What is the nurses priority for a client with decreased LOC?
A - Airway management B - Positioning C - IV access D - Fluid & nutritional support E - All of the above
A
What are the symptoms that occur with Cushing’s Triad?
Bradycardia, HTN, bradypnea
The nurse is aware that the most common
manifestation of a ruptured cerebral aneurysm
would be?
A - Tonic-clonic seizure
B - Decerebrate posturing
C - Narrowed pulse pressure
D - Sudden severe headache
D
Scenarios:
Child with an oral temp of 40C.
A friend at a party, falls from 1st story balcony and walks away.
Bring child to ER
Bring friend to hospital
damage to the spinal cord that results from direct injury to the cord itself or from indirect injury from damage to the bones, soft, tissue, blood vessels surrounding the cord
spinal cord trauma
What is the most costly medical condition in Canada?
SCI
Rick Hansen focuses on what?
the things HE CAN DO
SCI is a medical _________
emergency
Most important treatment for SCI?
Steroids to reduce swelling - methylprednisolone - ASAP
What is the important complication of SCI?
Autonomic dysreflexia
Massive uncompensated CV reaction. Simultaneous sympathetic and parasympathetic activity occurs
Autonomic dysreflexia
Autonomic dysreflexia:
- occurs in spinal cord injury above ___
- life threatening
- occurs in response to ________ stimulation. Most common causes?
T6
visceral
distended bladder, rectum or any wound
Autonomic dysreflexia symptoms:
- most important one? What do we do as a result?
Sudden acute headache
(BP of 300 torr)
if c/o headache in SCI patient, sit them up, take BP and do head to toe screen
Autonomic dysreflexia:
- it is important to teach patient and family the ______ and ______ of autonomic dysreflexia.
causes, symptoms
Most important complication of immobility for SCI patients?
Pressure ulcers
Rehabilitation nursing:
- Most important role?
Advocate
To maintain skin integrity in a client with a SCI, the nurse should do which of the following?
A - Catheterize regularly
B - Reposition every 3 hours while up in the wheelchair
C - Eat a high caloric, high fibre diet
D - Keep skin clean and moisture-free
D
Which of the following is an important teaching
point for bladder management?
A - Empty the bladder frequently
B - Over-hydrate (500ml/day)
C - Report concentrated urine to the physician
D - Wear loose fitting clothing
A
Fred is in rehab for a SCI. While providing
care, the nurse observes that he is flushed,
diaphoretic, complaining of a headache,
nausea, and he is bradycardic.
What is going on?
What should the nurse do?
Autonomic dysreflexia
Sit up, take BP, look for stimulus
