Exam 4 Flashcards
What organ are we worried about when dealing with electrical burns?
heart (dysrhythmias)
What kind of precautions are electrical burn pts on?
C-spine precautions because bone could be fractured
What is a 1st degree burn?
effects the epidermis
What is a 2nd degree burn?
effects the dermis
What does a 2nd degree burn look like?
shiny, moist, blistered
What is a 3rd degree burn?
total skin destruction
What does a 3rd degree burn look like?
black eschar, more white than level above
What is a 4th degree burn?
bones, muscles, tendons
What does a 4th degree burn look like?
dead tissue (don’t feel pain)
What is priority with emergent care of burns?
personal safety
When might care involve decontamination of the burn?
with chemical burns
What are two major risks for people with burns?
hypothermia
infection
Emergent care of wounds?
cool, lukewarm water and cover
Why does the nurse elevate extremities with burns?
to counteract inflammation
What is a major predictor of mortality in burn victims?
inhalation injuries
What two side effects can quickly develop with inhalation injuries?
airway compromise
pulmonary edema
What are the 3 types of inhalation injuries?
upper airway injury
lower airway injury
metabolic asphyxiation
What is a key finding with carbon monoxide poisoning?
cherry-red facial color
How does carbon monoxide poisoning work?
chemical binds with Hgb to decrease O2 carrying capacity
What are S/S of an inhalation injury? (10)
soot in mouth/nose
AMS
pale skin
decreased O2 sat
productive cough
increased work of breathing
hoarseness
stridor
wheezy/crackly lung sounds
burnt nasal hairs or eyebrow hairs
What is the duration of the resuscitation/emergent phase of a burn injury?
from onset of injury to completion of fluid resuscitation (72hrs)
What is the focus during the resuscitation/emergent phase of a burn injury?
ABCs and hemodynamic stabilization
What is the duration of the acute phase of a burn injury?
from beginning of diuresis to wound closure (72hrs)
What is the focus during the acute phase of a burn injury?
maintenance of cardiovascular and pulmonary systems
When is fluid resuscitation present?
when pts start to diuresis
What is the duration of the rehab phase of a burn injury?
from wound closure to optimal physical mobility
What is the focus during the rehab phase of a burn injury?
psychosocial adjustment - return to society
What are complications during the emergent phase of burn injuries? (5)
electrolyte imbalances
hypovolemic shock
third spacing
inflammation
immune changes
What is third spacing?
inflammation makes capillaries permeable which causes the movement of fluid into interstitial spaces
What is the sodium imbalance with major burns?
hyponatremic (Na going into cell)
What assessment is priority with hyponatremia?
neuro assess
What is the potassium imbalance with major burns?
hyperkalemic (K going out of cell)
What assessment is priority with hyperkalemia?
cardiac assess
What infusion restores vasculature and fluid volume?
albumin
What is the isolation protocol with major burns?
reverse isolation
What do nurses use the Parkland Formula for?
fluid resuscitation
How much of total fluid vol does the nurse administer over the 1st 8hrs?
1/2
How much of total fluid vol does the nurse administer over the next 8hrs?
1/4
How much of total fluid vol does the nurse administer over the last 8hrs?
1/4
What are the goals to maintain during fluid resuscitation?
SBP >90
HR <120
MAP >65
Urine output 0.5mL/kg/hr
(30-50mL/hr)
Under what circumstances will a burn pt be transferred to a burn center? (6)
face, hands, feet, genitalia, major joints
partial thickness burns >10% TBSA
3rd degree burns
electrical or chemical burns
inhalation injury
circumferential
What does circumferential mean?
burns are all the way around extremities, thorax, or neck
What is a high risk for circumferential burns?
compartment syndrome
With what type of burn injury is the development of compartment syndrome common?
full thickness injury; leathery eschar appearance
(3rd/4th degree burns)
What are S/E of compartment syndrome? (3)
lack of pulse in distal extremities
absence of movement
deep, aching pain
What is a escharotomy?
longitudinal incisions to relieve pressure from edema
What does cleaning the burn wound stimulate?
granulation and revascularization
What are 3 interventions for managing burn wounds?
debridement
hydrotherapy
dressings
How often are dressing changes with burn wounds?
daily
How often are dressing changes with skin grafts for burn wounds?
occlusive; changed q3-5 days
When can a nurse begin caring for a skin graft?
after the surgeon inspects it
What are 3 disorders of wound healing?
scars/keloids
contractures
failure to heal
What is autograft?
receiving a graft from your own tissue
What is allograft?
receiving a graft from another living thing
What interventions are included in nursing management of burns? (7)
PPE
airway management
fluid therapy
pain management
wound care
nutrition therapy
tetanus shot
Which meds are used IV during the emergent and acute phases of burn injuries?
morphine
fentanyl
Which meds are used for anxiety and pain management for burn injuries?
Lorazepam (ativan)
Midazolam (versed)
What are priority nursing management interventions during the acute phase of burn injuries? (5)
labs
infection
mobility
GI system
excision & grafting
What can happen to the GI system after a burn injury?
paralytic ileus, stress ulcers
intervention: NG tube
What kind of diet is recommended to a burn pt?
high calorie, high protein, high carbohydrate diet
Amount and frequency of meals for burn pt?
small portions, frequently
What meds are prescribed to burn pts to provide nutritional support?
insulin
carafate
histamine blockers
5-12 days after a traumatic injury what might happen to calorie needs?
double or triple
up to 5,000kcal
What is a nutritional high risk for burn pts?
hyperglycemia bc of insulin resistance
What is the MOA of Carafate?
coats lining of esophagus to prevent ulcers from forming
What are interventions for maintaining mobility with burn pts?
positioning
ROM exercises
ambulation
compression dressings
What is included in home care instructions for burn pts? (7)
skin & wound care
exercise & activity
physical & occupational therapies
nutrition
pain management
thermoregulation & clothing
mental health counseling
What is the exocrine function of the pancreas?
manufactures and secretes digestive enzymes
What enzyme breaks apart carbohydrates?
amylase
What enzyme breaks apart fats?
lipase
What enzymes break apart protein?
trypsin
chymotrypsin
What is the endocrine function of the pancreas?
manufactures and secretes insulin and glucagon
Pathophysiology of pancreatitis?
enzymes that are usually inactive until they reach the small intestine are activated in the pancreas and prompts inflammation
What is a hallmark sign of acute pancreatitis?
lipolysis
What occurs during lipolysis to the pancreas?
auto-digestion of pancreas (fibrosis)
Proteolysis may lead to…
thrombosis & gangrene of pancreas
What electrolyte imbalance is common with lipolysis?
hypercalcemia
What are pts at a high risk for because of proteolysis & necrosis of the pancreas?
risk for bleeding because of vasodilation
What might inflammation look like with acute pancreatitis?
pus formation, lesions
What are signs of acute pancreatitis?
lipolysis
proteolysis
necrosis of blood vessels
inflammation
How is chronic pancreatitis diagnosed?
repeated episodes (flare ups) of acute pancreatitis
What is the pathophysiology of chronic pancreatitis?
pancreatic secretions precipitate and plug pancreatic ducts leading to inflammation, fibrosis, ulcer formation, and the destruction of the secreting cells
What is the etiology of chronic calcifying pancreatitis?
alcoholism
What is the etiology of chronic obstructive pancreatitis?
inflammation, cholelithiasis
What is the etiology of autoimmune/genetic chronic pancreatitis?
immunoglobulins invade pancreas
What are pts with autoimmune/genetic chronic pancreatitis at a high risk of developing?
pancreatic cancer
What is the most common risk factor for pancreatitis?
gallstones
What are risk factors for developing pancreatitis? (7)
middle-aged man
alcoholism
trauma
smoking
familial
viral infection/abscesses
hyperlipidemia
What medications can cause pancreatitis? (3)
thiazides
NSAIDS
salicylates
If the cause of pancreatitis is related to alcoholism what is the prognosis?
poor
During what times of the year is pancreatitis most common?
during the holidays and vacation times
Manifestations of acute pancreatitis? (8)
N/V
Fever
Jaundice
Confusion & agitation
Ecchymosis in the flank or umbilical area
Hypovolemia & shock
Renal failure
Ascites
What is the key manifestation of acute pancreatitis?
severe abdominal pain
Manifestations of chronic pancreatitis?
Recurrent attacks of intense abdominal pain & back pain
Vomiting
Wt loss
Jaundice; dark urine
Foul smelling fatty stools (Steatorrhea)
S/S of diabetes
What are the 3 P’s of diabetes?
polyphagia
polydipsia
polyuria
What assessments are important for the nurse to perform on pts with pancreatitis?
GI & Skin assessments
What is Grey-Turner’s sign?
flank bruising indicating acute pancreatitis
What is Cullen’s sign?
bruising around the umbilicus indicating acute pancreatitis
What is a lab result that is highly indicative of acute pancreatitis?
elevated amylase within 12-24hrs
Which lab results are elevated with pancreatitis?
amylase
lipase
glucose
WBC
Which lab results are decreased with pancreatitis?
calcium & magnesium
What is ERCP?
Endoscopic Retrograde Cholangiopancreatography: invasive procedure where they inset stents or remove cysts
What two radiology diagnostics are utilized to diagnose pancreatitis?
CT
ultrasound
What is the primary nursing diagnosis associated with pancreatitis?
acute pain related to inflammation & enzyme leakage
What opioid medications are often prescribed to help manage acute pain related to pancreatitis?
morphine
dilaudid
fentanyl
(PCA pump)
What histamine receptor antagonists is often prescribed to help manage pancreatitis?
ranitidine
What PPI is often prescribed to help manage pancreatitis?
prilosec
What nursing intervention is often performed to manage pancreatitis?
NG tube insertion to decompression the stomach
What position often provides the most comfort to pts with pancreatitis?
fetal position
Why are PPI’s prescribed to pts with pancreatitis?
decreasing gastric acid production can promote enzyme replacement
What are secondary and tertiary nursing diagnoses for pancreatitis?
risk for fluid volume deficit related to fluid shifts
imbalanced nutrition less than body requirements
What are 3 nursing interventions for the risk for fluid vol deficit associated with pancreatitis?
IVF- isotonic solution (NS 150mL/hr)
NPO during acute period
I & O
What are 3 nursing interventions for imbalanced nutrition less than body requirements associated with pancreatitis?
NPO
antiemetics
enteral tube feeding
When is enteral feeding often initiated?
if NPO for 24-48hrs & no ileus
What must pts recovering from pancreatitis avoid when they return home?
alcohol & high fat foods
How many kcal may a pt with pancreatitis need a day?
4,000-6,000
What are 10 complications of pancreatitis?
death
infection (shock)
decreased CO (hypovol shock)
AKI
paralytic ileus
pleural effusion (L)
ARDS
DIC
MODS
DM type II
When can a pancreatitis pt discontinue the NPO status?
when serum amylase is normal, active bowel sounds, and no pain
What is pt education the nurse should provide when the pancreatitis pt is beginning to eat and drink again?
moderate to high carb, high protein, low fat diet
small, frequent, bland meals
avoid caffeine products
eliminate alcohol
may need pancreatic enzyme supplements
What additional pt education points may the nurse provide to the pancreatitis pt?
relaxed atmosphere
smoking cessation
What are S/S of pancreatitis complications? (8)
anorexia
n/v
abdominal distention with increasing fullness
persistent wt loss
severe epigastric or back pain
frothy/foul smelling BM
irritability, confusion
persistent fever
Because of hyperthyroidism what state does the body enter?
hyper-metabolic state
What hormones does the thyroid produce?
calcitonin
T3
T4
What are two risk factors for developing hyperthyroidism?
graves disease (autoimmune)
thyroiditis
What is the role of the pituitary gland?
promotes secretion and regulation of thyroid
What diagnostics are preformed to diagnose hyperthyroidism?
ultrasound
EKG
thyroid scan
In hyperthyroidism, the blood TSH level is
decreased
In hyperthyroidism, the T3 & T4 level is
elevated
What is a thyroid scan?
nuclear medicine
administer radioactive isotope day before scan and if there is elevated uptake of the isotope, hyperthyroidism can be diagnosed
What are nursing interventions for hyperthyroidism?
calm environment/safety
nutrition support, I & O, wt
eye protection (eye drops)
lower room temp (cold showers)
What medications are used to help manage hyperthyroidism?
thionamides (methimazole, propylthiouracil)
beta blockers
iodine solutions
What is the MOA of thioamides for hyperthyroidism?
inhibit the production of thyroid hormones by decreasing iodine use
What is the indication of beta blockers for hyperthyroidism?
palpitations
tachycardia
What is the MOA of iodine for hyperthyroidism?
short-term use
inhibit production of thyroid hormones
What are the treatments for hyperthyroidism?
iodine therapy
thyroidectomy
What are complications associated with a thyroidectomy? (5)
hemorrhage
thyroid storm/crisis
airway obstruction
hypocalcemia
nerve damage (vocal cords)
What is the MOA of iodine therapy?
destroys some thyroid producing cells
When is iodine therapy contraindicated?
pregnancy
What does iodine administration decrease?
size of thyroid gland
bleeding
What position should the pt be in after a thyroidectomy?
semi-folwers
What is a thyroid storm?
Common with graves disease and involves increased circulation of thyroid hormones in the blood.
What can be the result of thyroid storm?
high mortality rate
hypermetabolic state
What are S/S of thyroid storm? (6)
hyperthermia
HTN
SOB
delirium
vomiting
abdominal & chest pain
What are S/S of hypocalcemia? (3)
tetany
tingling of fingers/toes
convulsions
What condition can onset rapidly with hypothyroidism?
myxedema
What state does the body enter with hypothyroidism?
hypometabolic state
Why does hypothyroidism often go unnoticed?
can mimic normal aging process
What are risk factors for hypothyroidism? (3)
female (30-60 years)
inadequate intake of iodine
radiation therapy to head/neck
What area experiences hair loss with hypothyroidism?
eyebrows
What is myxedema?
swelling of face, tongue, hands
What diagnostics are performed to diagnose hypothyroidism?
thyroid scan
EKG
In hypothyroidism, the T3 and T4 level are
decreased
In hypothyroidism, the TSH level is
increased
In hypothyroidism, the cholesterol level is
increased
What are nursing interventions for managing hypothyroidism? (5)
monitor cardiac and respiratory systems
monitor wt, dietician consult
skin care
warming measures
stool softeners
What kind of diet is recommended with hypothyroidism?
low calorie/high bulk diet
What should the nurse refrain from administering to pts with hypothyroidism?
fiber laxatives
What is the treatment for hypothyroidism?
thyroid hormone replacement therapy
What is a possible complication of untreated hypothyroidism?
myxedema coma
What are S/S of myxedema coma? (5)
cold
respiratory failure
low BP
low BS
low HR
What kind of metabolism produces a build-up of lactic acid?
anaerobic
What are the 4 types of shock?
distributive
hypovolemic
cardiogeneic
obstructive
What are the 2 subcategories of hypovolemic shock?
absolute & relative
What is absolute hypovolemic shock?
external loss of whole blood or bodily fluids
What is relative hypovolemic shock?
fluid volume moves out of intravascular spaces and into interstitial spaces
What is obstructive shock?
there is a physical obstruction distrupting the heart’s functioning
What kind of complications can cause obstructive shock?
tension pneumothorax
cardiac tamponade
PE
What is cardiogenic shock?
the heart’s fault
What kind of complications can cause cardiogenic shock?
MI
dysrhythmias
What are the 3 types of distributive shock?
anaphylactic
neurogenic
septic
What is distributive shock?
excessive vasodilation that impairs blood flow
What are cardiovascular manifestations of shock?
tachycardia
hypotension
decreased cap refill
What is a cardiovascular manifestation unique to neurogenic distributive shock?
bradycardia
What are respiratory manifestations of shock?
tachypnea
What are respiratory manifestations specific to anaphylactic distributive shock?
wheezing
stridor
SOB
What are renal manifestations associated with shock?
decreased urinary output
What is a renal manifestation unique to neurogenic distributive shock?
bladder dysfunction
What are integumentary manifestations of shock?
pallor
cool, clammy skin
What are integumentary manifestations unique to septic distributive shock?
flushed skin
high temp
What are neurological manifestations associated with shock?
anxiety
confusion/agitation
AMS
What neurological manifestations are unique to neurogenic distributive shock?
flaccid paralysis
loss of reflexes
What are GI manifestations associated with shock?
hypoactive or no bowel sounds
What are GI manifestations unique to neurogenic distributive shock?
bowel dysfunction
What are GI manifestations unique to anaphylactic distributive shock?
n/v
What is involved in the initial stage of shock?
no manifestations except a build-up of lactic acid
What is involved in the compensatory stage of shock?
body is mounting measures to increase CO to restore tissue perfusion and oxygenation
What is involved in the progressive stage of shock?
compensatory mechanisms begin to fail
What is involved in the refractory stage of shock?
irreversible: total body failure
MODS
What are the 4 stages of shock?
initial
compensatory
progressive
refractory
What is the overall goal of treatment for cardiogenic shock?
restore blood flow to myocardium by restoring balance between O2 supply/demand
What is a priority nursing intervention for cardiogenic shock?
provide supplemental O2
What is the medical treatment for cardiogenic shock?
minimal fluid replacement
What pharmaceuticals may be prescribed with cardiogenic shock?
nitrates (nitro)
diuretics (furosemide)
dopamine/dobutamine
What should the nurse be cautious of when administering nitrates?
hypotensive manifestations
What is the MOA of diuretics?
decrease preload
What is the MOA of dopamine?
increase myocardial contractility
What is the MOA of dobutamine?
vasopressor
increase myocardial contractility
What are diagnostics utilized for cardiogenic shock?
CXR
EKG
lactic acid
What is the overall goal for hypovolemic shock?
stop the cause/bleeding/injury
What is the treatment for hypovolemic shock?
rapid fluid replacement
What is the 3:1 rule?
3mL of isotonic solution for every 1mL of estimated blood loss
What medications may be utilized with hypovolemic shock?
vasopressors (norepinephrine) Levophed
What is the positioning for optimal venous return?
supine w/ legs elevated
When would the nurse move to blood infusion when initiating fluid replacement?
after 500mL (1L) of fluids
What could happen to blood vessels if the nurse implements the use of vasopressors without initiating rapid fluid replacement?
they could collapse
What are the priority nursing interventions for hypovolemic shock?
providing supplemental O2
IV fluid bolus
bedrest while supine w/ legs elevated
What is the first manifestation the nurse will notice with a pt experiencing hypovolemic shock?
tachycardia
What is the overall goal of obstructive shock?
manage the obstruction
What interventions may be implemented to treat obstructive shock?
mechanical decompression
anticoagulation therapy
radiation, debulking, or removal of the mass/cause
What are 2 common causes of neurogenic shock?
SCI
spinal anesthesia
What is the patho of neurogenic shock?
loss of SNS vasoconstrictor tone = blood pooling & tissue hypoperfusion
What are manifestations associated with neurogenic shock?
hypotension
bradycardia
temperature dysregulation
What is poikilothermic?
the pt’s temperature matches that of the room’s
What medication can be used to treat hypotension?
vasopressor (Phenylephrine)
What is the difference btw neurogenic & spinal shock?
neurogenic shock is a hemodynamic condition
What does an allergic reaction cause systematically?
massive vasodilation
What is the patho of septic shock?
vasodilation = maldistribution of blood flow
What is the integumentary response during the progression of septic shock?
warm/flushed initially then progresses to cool/clammy
What lab values are elevated with septic shock?
lactic acid
BG
What is the treatment for septic shock?
the 1hr bundle
What diagnostics are utilized with the 1hr bundle?
CBC/CMP
blood cultures
lactate
blood coag studies
ABGs
What are the steps of the 1hr bundle?
- draw lactic acid level
- draw blood cultures
- admin broad spectrum antibiotics
- admin 1,000mL NS bolus
- If pt remain hypotensive, admin Levophed
What is an elevated lactic acid level?
> 2
What is a very elevated lactic acid level?
> 4
What is the standard fluid replacement rate?
30mL/kg
What must be present to diagnose as MODS?
failure of 2 or more organ systems
What occurs to the pt’s metabolism when experiencing SIRS?
hypermetabolic
SIRS?
systemic inflammatory response syndrome
What body system is the first to demonstrate MODS?
respiratory
MODS?
multiple organ dysfunction syndrome
What are respiratory findings associated with MODS?
alveolar edema (crackly)
ARDS (intubation)
What are cardiac findings associated with MODS?
decreased cap refill
dysrhythmias
What are neurologic findings associated with MODS?
comatose (extreme hypoxia)
What are renal findings associated with MODS?
AKI (accumulation of toxins)
What are metabolic findings associated with MODS?
hyperglycemia
insulin resistance
What are hepatic findings associated with MODS?
cannot covert lactic to glucose therefore the pt becomes hypoglycemic
What symptoms can indicate SIRS?
abnormal temp
increased RR
increased HR
abnormal WBC
decreased PCO2
What is WBC range?
4,000-12,000
How many symptoms must the pt exhibit to classify as SIRS?
2
What are the qualifications for classification of sepsis?
2 sirs
+
confirmed or suspected infection
What are the qualifications for classification of severe sepsis?
sepsis
signs of end organ damage
hypotension
lactate >4
What are the qualifications for classification of MODS?
presence of altered organ function
high levels of toxins
What are the qualifications for classification of septic shock?
severe sepsis w/ persistent hypotension
lactate >4
end organ damage
What are the 7 complications of shock?
MODS
ARDS
AKI
GI distress
hypermetabolic/catabolic
clotting issues
electrolyte imblances (acidotic)
What is DIC?
thousands of small clots form within organ capillaries, creating hypoxia & anaerobic metabolism = platelets and other clotting factors to be depleted = hemorrhage?
What happens to the platelet count with DIC?
decreases
What happens to the D-dimer with DIC?
increases
What happens to fibrinogen with DIC?
decreases
What happens to PT/aPTT with DIC?
increases
What is the nurse’s priority with DIC?
watch for excess bleeding
What should the nurse be prepared to admin for DIC treatment?
heparin
platelets
clotting factors
PRBC’s
PAWP value?
6-12mmHg
MAP value?
> 65mmHg
CVP value?
2-8mmHg
What does the CVP tell you?
how well blood is being pumped back to the heart
What does a high CVP indicate?
cardiogenic shock
What does a low CVP indicate?
hypovolemic shock
SV value?
60-160mL/beat
CO value?
4-8L/min
Alpha receptors MOA?
increase vasoconstriction
Beta 1 receptors MOA?
increase myocardial contractility
Beta 2 receptors MOA?
vasodilation of bronchi
What are the 3 vasopressors?
epinephrine (adrenaline)
norepinephrine (levophed)
dopamine
What are low doses of EPI used for?
code symptoms
anaphylactic shock
(cardiac stimulation & bronchodilation)
What are high doses of EPI used for?
IV drip
(peripheral vasoconstriction)
What is the gold standard med for treatment of septic shock?
norepinephrine (Levophed)
With what shock subcategories is dopamine utilized more often?
cardiogenic shock
septic shock
Why are vasopressors high risk meds?
they need to be administered with a central line because they can damage tissue
Dobutamine MOA?
positive inotropic med
What does a positive inotropic med do?
increased cardiac contractility
Why is dobutamine often administered with a vasopressor?
because it can cause vasodilation
With which type of shock is dobutamine most often utilized?
cardiogenic shock
What is vasopressin?
synthetic ADH (antidiuretic hormone)
What is the MOA of vasopressin?
ADH: Adds Da H2O to the body
(retain fluid, increase BP)
Nursing considerations for vasopressin?
monitor I & O
high risk med (central line)
Equation for CO?
HR x SV
SVR when vessels dilate?
decreases
SVR when vessels constrict?
increases
What is CO?
amount of blood pumped through the heart each miin
What is SV?
amount of blood pumped through the heart with each beat
Preload?
how much vol is pumping through system
Afterload?
forces opposing ejection
What is the trauma triad of death?
hypothermia
acidosis
coagulopathy
What are the 3 points after injury that a head injury could cause death?
immediately after
within 2hrs
about 3 weeks after
What are the 2 biggest causes of TBI?
falls and MVA
What are the 2 types of head injuries?
scalp lacerations
skull fractures
What are the 2 major complications associated with scalp lacerations?
blood loss
infection
What are the 3 major complications associated with skull fractures?
infection
hematoma
tissue damage
What are 2 signs of TBI?
raccoon eyes
battle’s sign
What is battle’s sign?
bruising behind ear
When present what indicates the presence of CSF leakage?
glucose
What are the tests for CSF leaks?
dextrostix
tex-tape
B2 transferrin
halo sign
If there is CSF leakage what is a possible complication?
meningitis
What is the gold standard test for CSF leak?
B2- Transferrin
What are 2 examples of diffuse head injuries?
concussion
diffuse axonal injury
What is a minor diffuse head injury GCS score?
13-15
What is a severe diffuse head injury GCS score?
3-8
What are 2 examples of focal head injuries?
contusion
hematoma
What are unique S/S of focal head injuries?
headache & pupillary effects on affected side
S/S on opposite side of injury
What does the GCS assess?
eyes
voice
motor
What are early signs of increased ICP?
decreased LOC
irritability
sleepiness
flat affect
headache
vomiting
What are late signs of increased ICP?
cushing’s triad
seizures
coma
abnormal posturing
pupillary changes
What is Cushing’s Triad?
HTN (wide pulse pressure)
bradycardia
cheyenne-stokes respirations
What are S/S of post-concussion syndrome?
persistent headache
lethargy
personality changes
shortened attention span
decreased short-term memory
changes in intellectual ability
What TBI has the highest mortality rate?
diffuse axonal injury
Who is at high risk for developing a contusion head injury?
elderly pts on anticoagulants
Which hematoma type is a medical emergency and why?
epidural bc it develops quickly
When does an intracerebral hematoma occur?
2-14 days
When does a subarachnoid hematoma occur?
weeks-months after injury
At what pressure does the nurse want to maintain SBP at with head injury pts?
> 100mmHg
What is the best diagnostic test to evaluate for head trauma?
CT scan
What does a transcranial doppler measure?
cerebral blood flow velocity
If a pt loses consciousness for greater than ____min more severe complications?
30
What factors make up content of brain?
CSF
intravascular blood
brain tissue
What factors influence ICP?
intrabdominal & intrathoracic pressure
posture
temp
CO2 levels
What kind of relationship does CSF, intravascular blood, and brain tissue have?
inverse
What is the Monro-Kellie Doctrine?
compensatory mechanisms to maintain normal ICP
*after injury, initially no increase in ICP
What is the normal ICP?
5-15mmHg
What ICP value requires treatment?
> 20mmHg
What is the normal CPP value?
80-100mmHg
What CPP value causes cerebral ischemia?
<60mmHg
What CPP value indicates brain death?
<30mmHg
How is CPP calculated?
MAP-ICP
What are the first 2 symptoms noticed with decreasing CPP?
dizzy
blurred vision
What meds do nurses use to manipulate MAP?
pressors
What meds do nurses use to manipulate ICP?
mannitol/hypertonic solutions
How many stages of increased ICP are there?
4
What is involved in the 3rd stage of increased ICP?
failing compensation
(Cushing’s triad)
If ICP is elevated for too long what is the result?
brain herniation (respiratory changes)
When auto-regulation of cerebral blood flow fails what is the result?
cerebral edema
What is the normal PCO2 level?
35-45
What is the result of increased CO2 on cerebral blood flow?
dilates cerebral blood vessels and increases ICP
What is the result of decreased CO2 on cerebral blood flow?
severe vasoconstriction resulting in severe hypoxia
What does the pupillometer do?
measures pupil at peak dilation
When does the RN need to report to the provider a pupillary change?
> 1mm
What is the normal pupil exam?
3-4mm
With an EVD the transducer must be level with the?
tragus of the ear
What increases the risk of infection with EVD?
in place more than 5 days
CSF leak
systemic infection
What cleaning technique is used when working with EVD?
aseptic
When might the provider instruct the RN to remove CSF from EVD?
> 20
How long must the EVD be clamped for an accurate reading of CSF vol drained?
at least 6min
What is the time frame for intermittent drainages of CSF with an EVD?
30-120 sec
What is a possible complication if more than 20mL of CSF is drained in a hr?
ventricles could collapse
What kind of drug is mannitol?
osmotic diuretic
Route of admin for mannitol?
IV
How does mannitol decrease IVP?
plasma expansion
osmotic effect
What does the RN monitor with the admin of mannitol or hypertonic solutions?
serum electrolytes
BP
What are 2 examples of hypertonic solutions?
3% NaCl
D5W
What medication is given as a prophylactic for GI bleeds and gastric ulcers?
H2 Receptor Antagonists
Ranitidine (Zantac)
What medication is given to pts with increased ICP as antiseziure?
phenytoin (Dilantin)
What can be a S/E of propofol?
hypotension
What are the 3 main nursing interventions for increased ICP?
maintain patent airway
ICP within normal limits
normal fluid & electrolytes
What can raise abdominal pressure?
hip flexion
What are nursing considerations with suctioning?
maximum of 2 passings
maximum of 10sec
oxygenate before and after
Why might a pt with increased ICP have an NG tube?
nutrition and prevent abdominal distension
Diabetes Insipidus is caused by
decrease of ADH (hypernatremia)
What is the treatment for Diabetes Inspidus?
fluid replacement
SIADH is caused by
excess ADH (hyponatremia)
At what temp does the RN want to maintain a pt with increased ICP?
96.8-98.6
What opioids are commonly used with increased ICP pts?
fentanyl & morphine
MOA of propofol (Diprivan)?
used to manage anxiety & agitation (sedation)
* doesn’t control pain
MOA of Precedex (Dexmedetomedine)?
sedation
*no pain control
MOA of Nimbex (Cisatracuriu m)?
sedation
* no pain control
Why might benzos not be used with treatment of increased ICP?
longer effects
hypotension
Urinary output with diabetes insipidus?
high
Urinary output with SIADH?
low
Specific gravity of diabetes insipidus urine?
low (dilute urine)
Specific gravity of SIADH urine?
high (concentrated urine)
What is the treatment for SIADH?
diuretics, fluid restriciton
What kind of disorders of TBI pts most at risk for developing?
seizure disorders
Personality changes are expected after pt is comatose for?
6hrs or more