Module 5 Flashcards
What are some reasons that making triageing in the ER more difficult?
ER patients presenting with more complex issue
Lack of resources
Lack of acute care beds
ED overcrowding
What are some causes an altered level of consciousness?
A− Acidosis, Alcohol Intoxication E− Epilepsy, Encephalitis I− Insulin Reaction O− Overdose U− Uremia, Underdose T− Trauma, Tumor I− Infection P− Psychosis S− Stroke
What clasifys a CVA/stroke?
Is a sudden loss of brain function chatacterized by neurological dficits that persists for 24 hours or more
What is a ischemic stroke?
Interruption of blood flow to the brain
What is a hemorrhagic stroke?
The ruptured of blood vessels in the brain
What would you classify someone who you suspect is having a stroke?
CTAS 2
What is intracranial pressure?
The pressure exerted on the ventricles by cerebrospinal fluid
What is the formual of cerebral perfusion pressure?
Cerebral perfusion pressure= MAP (mean atrial pressure) - ICP (Intracranial pressure)
What is the brain made up of?
80% brain tissue, 10% blood, and 10% CSF
What type of day to day activities can increase ICP?
Coughing, sneezing or straining
What is the munro-Kellie hypotheisis?
eciprocal compensation among the three intracranial compartments (brain, blood, and CSF). A slight increase in one volume can be compensated by a decrease in one or both of the other two volumes.
What is the issue if ICP continues to rise?
the origin of the increase or the compensation that occurs, intracranial pressure will continue to build until the problem is addressed. And once compensatory mechanisms are exhausted, which happens incredibly quickly, ICP increases at a rapid rate
How does the body react to an increase in volume?
Compensation limited to CSF movement down the spinal cord
CSF production decreases
Small amount of distension of the dura mater
What about when the pressure builds? (B-C) on the chart?
As pressure builds, the venous system is compressed
Brain compression occurs and ICP begins to rise
What about when all compensation fails?
Increased pCO2 causes cerebral vasodilation which increases blood flow to the brain and there is a dramatic increase in ICP
What are the reasons for rapid increase in ICP?
Pressure builds, the vennous system is compressed and the blood volume beings to increase because the outflow is blocked
ICP rises quickly, all compensatory mechanisms fail, and the resulting increased pCO2 causes cerebral vasodialtion, further increasing the blood volume in the brain and dramatically increasing ICP
What is the formula for ICP?
ICP= MAP-CPP
How do we measure ICP in ED?
Although it cannot be directly measured, ED nurses depend on the patients history leading to admission and symptoms of increase ICP
What is the standarizied tool for assessing LOC?
Glasgow coma scale
When you are testing pupil response, what crainal nerve are you testing?
CN 3
When checking pupil repsonse, what are you looking for?
Pupils are equal, round, reactive to light (accommodating)
What cranila nerves are responsible for extraoccular movement?
CN 3,4, 6
Where does voluntary motor movement control come from?
Frontal lobe
What are some ways to test motor function in limbs?
Squeeze your fingers with their hands
Push their arms against your hands as you gently push down
Push their geet against your hands in a extending motion and pull their feet against your hands in a flexion motion
What 3 things make up cushings triad?
Hypertension with a wide pulse pressure
Bradycardia
Abnormal respiratory patterns
What are some early signs of increasing ICP in regards to motor response?
monoparesis or hemiparesis
What is decortication?
is characterized by abduction of the arm at the shoulder with flexion at the elbow and pronation and flexion at the wrist; the legs extend at the hips and knees. (This is also called abnormal flexion.)
What is decerebration?
includes extended, adducted, and internal rotation of the arm; flexion of the wrist and fingers; the legs are extended and the feet are plantar flexed. (This is also called abnormal extension.)
What is cushing’s response?
Is a late compensatory mechanism geared to provide adequate cerebral perfusion pressure in the presence of rising ICP. Systolic BP rises and heart rate decrease as incoming MAP attempts to overcome rising ICP
What effects does dexamethasone have on ICP?
Decrease cerebral edema
True or false
Increased ICP causes low BP due to hypovolemia?
False
Which cranial nerves control the patient’s eyes to follow your finger when you move it before them?
cranial nerves III, IV, and VI
What is ICP?
The pressure exerted on the ventricles by CSF
What is the best practice for nursing assessment to rouse a patient?
Trapezius squeeze
An objective finding that suggest a potential increase in ICP?
Bradycardia, irregular respirations, hypertension
