Adult II Exam 3 Case Studies

Glasgow Coma Scale
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Terms in this set (20)
Glasgow Coma Scale
-eye opening
-motor response
-verbal response
Increasing ICP signs
-altered respiratory pattern
-dilation of pupil w/ sluggish or no response to light
-increased systolic pressure
-contralateral hemiparesis
-slowing heart rate
-vomiting
-change in level of consciousness
-blurred or double vision
Priority action for head injury and increasing ICP
notify the ED physician of the patient's change in condition
100% oxygen
ensures adequate oxygenation to support brain function
HOB elevated 30 degrees
promotes venous drainage from the brain
Endotracheal intubation and mechanical ventilation
maintains airway and ventilation
Response to wife for need of surgery
Her husband has acute bleeding that if controlled with surgery dramatically improves his chances for recovery
The first ICP measurement is 10 mm Hg, and the waveform shows P waves in which P1 is higher than P2 and P3. First action?
Document findings and continue with planned care.

(Normal ICP 5-15 mm Hg, and P waves in descending amplitude are normal waveforms)
Draining CSF via ventricular catheter: drip chamber and drainage bag should be placed at ventricular reference point "foramen of Monroe". Where?
tragus of the ear or outer cannthus
Interventions that increase ICP
-coughing and sneezing
-endotracheal suctioning
-extreme hip and neck flexion
-fear and anxiety
-PaCo2 of 52 mm Hg
-pain
-Valsalva maneuver
-rapid changes in position
Mannitol (Osmitrol)expands plasma and increases cerebral blood flow while osmotic diuresis decreases ICPSpinal cord injury interventions-X-rays of the spine -Spinal CT scan and/or MRI -Administration of atropine -Administration of vasopressors such as dopamine -Insertion of NG tube to suction -Insertion of an indwelling catheter -Initiate 2nd IV site w/ large-bore catheter -Administer oxygen -Cardiac monitoringSpinal shock-decreased reflexes below the level of the injury -loss of sensation -flaccid paralysis -lasts for days to monthsNeurogenic shock-hypotension -warm -dry skin -bradycardia (due to loss of function of part of sympathetic nervous system)Necrotic destruction of the spinal cord-hemorrhage -vasospasm -norepinephrine, serotonin, and dopamine -edema -hypoxiaC8 injuryloss of grip strengthNeurogenic shock: Kinetic treatment bed-inspect skin over all areas at least q2h -assess the patient's ability to count to 10 aloud without taking a breath -notify the physician if PaO2 is less than 60 mm Hg and if PaCO2 is greater than 45 mm Hg -Use compression gradient stockings or pneumatic compression devices on calves -auscultate bowel sounds at least q4h and monitor for abdominal distention -maintain accurate intake and output records -provide stimulation of vision, smell, and hearing to compensate for sensory deprivationCervical laminectomy complications-UTI -pneumonia -DVT -pressure ulcers -paralytic ileusAutonomic dysreflexiasympathetic nervous system response to sensory stimulation resulting in marked hypertension (symptoms include headache and blurred vision)Autonomic dysreflexia interventions-take blood pressure and pulse -elevate head of bed -check the bladder for distention -catheterize the bladder