CCRN: Neuro Flashcards
neuro
CPP with an increased ICP should be held at 70 mm-Hg … .why?
to ensure adequate blood supply to the brain due to the increase in ICP.
the most sensitive indicator of ICP changes in someone unresponsive is…
blood pressure….. the change in ICP will stimulate the sympathetic nervous system and directly effect systolic blood pressure.
nursing intervention for the neurological patient should include…
NOT CLUSTERING ACTIVITIES….. causes too much stimulation and will increase ICP.
tell me what you know about subdural bleeds
it can be acute (first 48 hrs), subacute (w/in 2 days), or chronic (after 2 weeks)… large vein effected is usually acute
tell me what you know about epidural bleeds…
usually arterial…. usually seen temporally…. LOC initially… lucid then LOC again (typical of arterial)…. surgery to fix
tell me what you know about subarrachnoid bleeds
usually arterial… happens deep in the base of the brain… circle of willits… could be from an ischemic part in the circle and cause aneurysm
tell me what you know about intracerebral bleed
usually seen from a patient on anti-coagulants or from a trauma… slow developing…. poor prognosis…. decreased LOC
unruptured aneurysm signs and symptoms…
dialated pupils, neck rigidity, eye pain, localized headache, extra ocular eyemovement, photophobia
ruptured aneurysm in the subarrachnoid or intracerebral…
decreased LOC, n/projectile vomiting, “worse headache of my life”, seizures
hunt-hess classification of subarachnoid hemorrhages
grade 1: asymptomatic/ grade 2: mild cranial nerve dysfunction/ grade 3: mild focal deficit, lethargy, confusion/
grade 4: decreased LOC, hemiparesis, abnormal posturing/ grade 5: deep coma, posturing
the most important thing to monitor after a seizure is the respiratory pattern and EKG..why?
because during the seizure, d/t the increased brain activity, the patient could have used up most of the fuel of the brain - the glucose… which could effect other things the brain monitors… like respirations and heart rhythms.
