Class 14 Flashcards
Neurons are exquisitely sensitive to ______ deprivation
glucose
Can neutrons store glucose?
no
Increased intracranial pressure is?
pressure within the cranium (skull)
ICP is dependent on the relationship between?
brain tissue, CSF and blood
Is pressure in the brain normally low or high?
low (5-15mmHg)
monro-kellie hypothesis
volume inside the cranium is fixed. Any increase in volume of one component results in the decrease of another.
ICP occurs when?
compensatory mechanisms are no longer effective
increased intracranial pressures will ______ cerebral perfusion
decrease
what is the end result of increased intracranial pressure
brain tissue displacing
Herniation
bulge and push of brain tissue down to cerebellum and around spinal cord
Main manifestations of ICP are?
altered level of consciousness, pupillary alteration, changes in vital signs
what is the earliest indicator of increased intracranial pressure
change in the level of consciousness
in what stage are changes in vitals signs seen?
in stage 3 (beginning decompensation)
what is the most critical index of nervous system function?
Level of consciousness
How is LOC assessed?
using the Glasgow coma scale
what is the highest score you can get on the GCS?
15/15
What is the lowest score you can get on the GCS?
3/15
what are the 3 categories of the GCS?
eye opening, verbal response and motor response
If the patient being assessed for LOC does not respond to speech, what must the nurse do next?
elicit pain by applying pressure to nail beds or trapezius muscle
impaired judgement or decision making and loss of ability to think rapidly and clearly
confusion
If a person cannot answer time, place or self, they have?
disorientation
limited spontaneous movement, easy arousal with speech or touch
lethargy
mild-moderate decrease in awakeness with limited response to environment. Falls asleep unless stimulated, answers with minimal response.
obtundation
deep sleep, may be aroused only by vigorous and repeated stimulation. Response is usually withdrawal or localizing.
stupor
no verbal response. Noxious stimuli such as deep pain do not yield movement. GCS = 3
coma
pupils will initially change on the?
same side as brain injury
what is the worst type of pupil alteration to have?
fixed and dilated
normal pupillary response?
pupils should be equal and reactive to light
Cushing’s triad
- Bradycardia
- Widening pulse pressure
- Irregular respirations
Is Cushing’s triad a late or an early finding?
LATE finding
What is Cushing’s triad indicative of?
impending herniation
