Test 3 - Extra Focus Flashcards
MAP Equation
[(2 x diastolic) + systolic] / 3 = MAP
CPP Normal
60 - 80
CPP Equation
MAP - ICP = CPP
Sodium max level
160
ABG CO2
35 - 38
End Tidal CO2
30 - 35
Thrombolytic Exclusion Labs
- Plt <100,000
- INR >1.7
- High PTT
ALT
10 - 130
AST
10 - 34
Autonomic Dysreflexia: S/S
- HA, flushing, warmth
- HTN
- Bradycardia
- Anxiety
- Skin cool below LOI
Autonomic Dysreflexia: Interventions
- Elevate HOB
- Remove stimulus
- V/S checks q2-5 minutes
- IV meds (if BP remains elevated)
Vasospasm: Nursing Responsibilities
-Monitor for S/S (LOC changes -> assess with GCS)
Day 4-14 post op
-Transcranial doppler
-Hemodynamic augmentation
Vasopressors (Dopamine and Nor-Epi)Basilar Skull Fracture: S/S
- CSF leak
- Facial Palsy
- Facial numbness
- Deafness
- Hemotympanum
- Battle’s Sign
- Raccoon Sign
- Nystagmus
Basilar Skull Fracture: Nursing Care
- Assess vision, smell, hearing
- Nothing in the nose
- HOB 30 degrees
- Avoid strain/cough/sneeze
- Watch for meningitis s/s
- Administer abx
Surgery needed is CSF leak >1 week
Basilar Artery Syndrome
Affects the brainstem; 95% fatality
S/S:
- Dizziness
- Ataxia
- Tinnitus
- Nausea/Vomiting
- One sided weakness
Testing: pt. touch nose, touch RN finger, repeat
Possible Activity with Injury to: C4 and higher
None
Possible Activity with Injury to: C5
May be able to feed/dress self with assistive devices
Possible Activity with Injury to: C6 - C8
Specialized motorized wheelchair and/or car use possible
Possible Activity with Injury to: T1 - T10
Independent self-care, manual wheelchair
Possible Activity with Injury to: T11 - L5
Can walk short distances with braces
Possible Activity with Injury to: S1 - S5
Free roaming - may use braces
Motor Assessment: C4 and C5
Shrug shoulders
Motor Assessment: C5 and C6
Pull up arms
Motor Assessment: C8
Form a fist, grab an object
Motor Assessment: L5
Apply resistance with dorsiflexion of feet
Brain Tumor: S/S
- Headache (worse in the am)
- Vomiting
- Personality changes
- Aphasia (loss of speech/language comprehension)
- Ataxia (impaired coordination)
Increased ICP: S/S
- LOC change
- Pupil changes (ipsilateral; bilateral is worsened)
- Papilledema
- Motor changes
- HA
- Projectile vomiting
- Cushing’s Triad
GCS: Motor
6 - Obeys commands 5 - Moves to localized pain 4 - Flexion withdrawal from pain 3 - Abnormal flexion (decorticate) 2 - Abnormal extension (decerebrate) 1 - No response
GCS: Eye Opening
4 - Spontaneous
3 - To speech
2 - To pain
1 - No response
GCS: Verbal Response
5 - Oriented to time, place, and person 4 - Confused 3 - Inappropriate words 2 - Incomprehensible sounds 1 - No response
