| Term | Definition |
|---|
| subdural hematoma | more common in "older" population because of cerebral atrophy (Sole 383) |
| glascow coma scale | standardized tool used to assess neurological status (Sole 383) |
| eye opening, verbal response, motor response | three components of the glascow coma scale(Sole 383) |
| normal intracranial pressure (range) | ICP ranges from 0-15 mm Hg (Sole 389) |
| increased intracranial pressure (definition) | ppressure of 20 mmHg or greater persisting for >= 5 minutes (Sole 389) |
| herniation | caused by sustained increase in intracranial pressure (Sole 389) |
| ventriculostomy | utilized for both ICP monitoring and drainage of excessive cerebral spinal fluic (Sole 391) |
| zero reference point for ventriculostomy | foramen of monroe |
| nursing activities associated with increased intracranial pressure | turning, repositioning, and suctioning (Sole 394) |
| ICP monitoring goal | maintain ICP < 20 mmHg and CPP > 70 |
| endotracheal suctioning increases ICP | Interventions: hyperoxygenate with 100% oxygen-before, and for 1 minute after |
| suctioning attempts should be limited | to < 10 seconds with no more than 2 passes (Sole 394) |
| EBP has shown family presence | lowers ICP (Sole 399) |
| family teaching should include | avoid excess stimulation of patient (Sole 399) |
| maintain PaO2 greater than 80 mmHg | rationale? ensures oxygen delivery to brain exceeds oxygen demand (Sole 399) |
| PaCO2 should be maintained | between 35-45 mmHg (Sole 400) |
| Serum osmolarity | should be maintained between 310-320 mOsm/L (Sole 400) |
| Mannitol | draws water from normal brain cells into plasma resulting in a decrease in ICP |
| Filter needle | used to withdraw mannitor prior to administration (Sole 401) |
| Mannitol side effects | hypotension, electrolyte disturbance, tachycardia, rebound ICP (Sole 401) |
| Mannitol contraindicated in patients with | dehydration or renal failure |
| Cerebral Blood Flow | CPP is the pressure needed to provide blood flow to brain (Lecture) |
| CPP should be maintained at | > 60 mmHg |
| MAP-ICP= | CPP |
| Increased PCO2 | Vasodilation and Increase is ICP (lecture) |
| Decreased PCO2 | Vasoconstriction and decrease in ICP (lecture) |
| decorticate posturing | Abnormal flexion due to damage in corticospinal tract (Sole 385) |
| decerebrate posturing | abnormal extension due to damage in midbrain or pons (Sole 385) |
| signs and symptoms of basilar skull fracture | battles sign(brusing behind ear), Raccoon's eyes (bruising around eyes, spinal fluid leakage |
| Otorrhea | spinal fluid leak from ears |
| Rhinorrhea | spinal fluid leak from nose |
Combine with other sets
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