Module 5

Question 1

What are some reasons that making triageing in the ER more difficult?

Answer 1

ER patients presenting with more complex issue
Lack of resources
Lack of acute care beds
ED overcrowding

Question 2

What are some causes an altered level of consciousness?

Answer 2

A− Acidosis, Alcohol Intoxication
E− Epilepsy, Encephalitis
I− Insulin Reaction
O− Overdose
U− Uremia, Underdose
T− Trauma, Tumor
I− Infection
P− Psychosis
S− Stroke

Question 3

What clasifys a CVA/stroke?

Answer 3

Is a sudden loss of brain function chatacterized by neurological dficits that persists for 24 hours or more

Question 4

What is a ischemic stroke?

Answer 4

Interruption of blood flow to the brain

Question 5

What is a hemorrhagic stroke?

Answer 5

The ruptured of blood vessels in the brain

Question 6

What would you classify someone who you suspect is having a stroke?

Answer 6

CTAS 2

Question 7

What is intracranial pressure?

Answer 7

The pressure exerted on the ventricles by cerebrospinal fluid

Question 8

What is the formual of cerebral perfusion pressure?

Answer 8

Cerebral perfusion pressure= MAP (mean atrial pressure) - ICP (Intracranial pressure)

Question 9

What is the brain made up of?

Answer 9

80% brain tissue, 10% blood, and 10% CSF

Question 10

What type of day to day activities can increase ICP?

Answer 10

Coughing, sneezing or straining

Question 11

What is the munro-Kellie hypotheisis?

Answer 11

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.

Question 12

What is the issue if ICP continues to rise?

Answer 12

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

Question 13

How does the body react to an increase in volume?

Answer 13

Compensation limited to CSF movement down the spinal cord
CSF production decreases
Small amount of distension of the dura mater

Question 14

What about when the pressure builds? (B-C) on the chart?

Answer 14

As pressure builds, the venous system is compressed

Brain compression occurs and ICP begins to rise

Question 15

What about when all compensation fails?

Answer 15

Increased pCO2 causes cerebral vasodilation which increases blood flow to the brain and there is a dramatic increase in ICP

Question 16

What are the reasons for rapid increase in ICP?

Answer 16

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

Question 17

What is the formula for ICP?

Answer 17

ICP= MAP-CPP

Question 18

How do we measure ICP in ED?

Answer 18

Although it cannot be directly measured, ED nurses depend on the patients history leading to admission and symptoms of increase ICP

Question 19

What is the standarizied tool for assessing LOC?

Answer 19

Glasgow coma scale

Question 20

When you are testing pupil response, what crainal nerve are you testing?

Answer 20

CN 3

Question 21

When checking pupil repsonse, what are you looking for?

Answer 21

Pupils are equal, round, reactive to light (accommodating)

Question 22

What cranila nerves are responsible for extraoccular movement?

Answer 22

CN 3,4, 6

Question 23

Where does voluntary motor movement control come from?

Answer 23

Frontal lobe

Question 24

What are some ways to test motor function in limbs?

Answer 24

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

Question 25

What 3 things make up cushings triad?

Answer 25

Hypertension with a wide pulse pressure
Bradycardia
Abnormal respiratory patterns

Question 26

What are some early signs of increasing ICP in regards to motor response?

Answer 26

monoparesis or hemiparesis

Question 27

What is decortication?

Answer 27

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.)

Question 28

What is decerebration?

Answer 28

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.)

Question 29

What is cushing’s response?

Answer 29

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

Question 30

What effects does dexamethasone have on ICP?

Answer 30

Decrease cerebral edema

Question 31

True or false

Increased ICP causes low BP due to hypovolemia?

Answer 31

False

Question 32

Which cranial nerves control the patient’s eyes to follow your finger when you move it before them?

Answer 32

cranial nerves III, IV, and VI

Question 33

What is ICP?

Answer 33

The pressure exerted on the ventricles by CSF

Question 34

What is the best practice for nursing assessment to rouse a patient?

Answer 34

Trapezius squeeze

Question 35

An objective finding that suggest a potential increase in ICP?

Answer 35

Bradycardia, irregular respirations, hypertension