Neurological system Flashcards
1
Q
Signs of increased intracranial pressure (early signs)
A
- Headache
- Visual disturbances, diplopia
- Nausea and vomiting
- Dizziness or vertigo
- Slight change in vital signs
- Pupils not as reactive or equal
- Sunsetting eyes (cranial nerve IV palsy; the iris of eye appears to be setting into the lower eyelid leaving sclera visible above the iris)
- Slight change in level of consciousness, restlessness
2
Q
Signs of increased intracranial pressure: progression
A
Same as early signs plus:
* Irritability
- Bulging fontanelle
- Wide sutures, increased head circumference
- Dilated scalp veins
- High-pitched, catlike cry
3
Q
Signs of Increased Intracranial Pressure: Late Signs
A
- Significant decrease in level of consciousness
- Seizures
- Cushing triad - Increased systolic blood pressure and widened pulse
pressure (systolic pressure increases as the diastolic pressure
stays the same or decreases), bradycardia and irregular respirations - Fixed and dilated pupils, papilledema
4
Q
Nursing management of seizure
A
- Remain calm, stay with the child, and prevent the child from injury
during the seizure - A child who is standing or seated in a chair is eased to the floor
immediately - The swallowing reflex is lost, salivation increases, and the tongue hypotonic therefore risk for aspiration and airway occlusion. Place the child on the side to facilitate drainage and help maintain a patent airway. Suctioning of the oral cavity and posterior oropharynx may be necessary.
- Do not attempt to stop a seizure – restraining the child can cause
injury - Do not place anything in the child’s mouth – can cause injury
- Loosen restrictive clothing
- Create a safe environment
5
Q
Nursing diagnoses
A
- Ineffective Breathing Pattern
- Aspiration, Risk for injury
- Risk for Impaired Skin Integrity
- Interrupted Family Processes
- Acute Pain
