NUR 2462C Chapter Notes - Chapter 1: Cerebral Perfusion Pressure, Glasgow Coma Scale, Abnormal Posturing

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Published on 8 Jun 2020
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SPC THREATS TO NEUROSENSORY INTEGRATION
NUR2731C/NEURO 1 Fall, 2016
ST. PETERSBURG COLLEGE
COLLEGE OF NURSING
ASSOCIATE DEGREE NURSING PROGRAM
NUR 2731C - NURSING IV
UNIT III: THREATS TO NEUROSENSORY
KEY TERMS
Autoregulation- regulation of blood flow
Cerebral edema- swelling in the brain caused by presence of excessive fluid
Cerebral perfusion pressure (CPP)- Pressure needed to ensure blood flow to the brain. CPP= MAP-ICP
Concussion- Brain injury that may alter the way the brain functions. May have brief disruption/ loss of LOC. Retrograde
amnesia, H/A of short duration.
Contusion- Bruising of brain tissue. Can be caused by hematoma, Infarction, or edema (increased ICP)
Coup (contusion resulting from the brain contacting the skull on the side opposite from where impact occurs)
Contracoup phenomenon- head injury in the form of cerebral contusions. Think whiplash
Craniotomy- surgical opening into the skull
Cushing’s triad- Increased systolic pressure with widening pulse pressure, Bradycardia with a full bounding pulse, and
an irregular. Slow respiration
Decerebrate posturing- abnormal body posture that involves the arms and legs being held straight out, the toes being
pointed downward, and the head and neck being arched backwards
Decorticate posturing- a sign of damage to the nerve pathway between the brain and spinal cord. Posturing may occur
on 1 or both sides of the body.
Diabetes insipidus- rare disorder that occurs when a person's kidneys pass an abnormally large volume of urine that is
insipiddilute and odorless.
Epidural hematoma- results from bleeding between the dura and inner surface of the skull. A neurological emergency.
Can either be venous or arterial in origin.
Glasgow Coma Scale- a quick, practical standardized system for assessing LOC
ICP monitoring (Intracranial Pressure)- a device, placed inside the head. The monitor senses the pressure inside the
skull and sends measurements to a recording device.
Intracerebral hematoma- occurs when blood pools in the brain
Monro-Kellie doctrine- An increase in ICP decreases cerebral perfusion pressure (CPP) which worsens cerebral
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SPC THREATS TO NEUROSENSORY INTEGRATION
NUR2731C/NEURO 2 Fall, 2016
ischemia
Subdural hematoma- Occurs from bleeding between the dura mater + arachnoid meningeal coverings of the brain
Syndrome of inappropriate antidiuretic hormone- The syndrome of inappropriate antidiuretic hormone (ADH) secretion
(SIADH) is defined by the hyponatremia and hypo-osmolality resulting from inappropriate, continued secretion or action
of the hormone despite normal or increased plasma volume, which results in impaired water excretion.
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SPC THREATS TO NEUROSENSORY INTEGRATION
NUR2731C/NEURO 3 Fall, 2016
UNIT OBJECTIVES
THREATS TO NEUROSENSORY
1. Review the physiologic mechanism that maintains normal intracranial pressure.
Normal ICP is 0-15 mm gh
2. Review the signs and symptoms of increased intracranial pressure.
Called Cushing’s Triad
Increasing systolic pressure
Widening pulse pressure
Bradycardia (relative bradycardia)
With full, bounding pulse
Irregular, slow respiration
Factors that Influence ICP: Changes in the following:
Arterial Pressure
Venous Pressure
Intra-abdominal Pressure
Intra-thoracic Pressure
Posture
Temperature
Blood Gases (especially CO2 levels)
Factors that affect CBF
Oxygen
Carbon Dioxide
Hydrogen Ion concentration Lactic Acid (*Acidosis) potent vasodilator and makes it worse
3. Review appropriate assessment techniques to determine significant subjective and objective assessment
data (including age-related changes) related to increased intracranial pressure (neuro exam and Glasgow
coma scale).
A. CLINICAL EXAMPLE: CLIENTS WITH INCREASED INTRACRANIAL PRESSURE RELATED TO HEAD INJURY
(FRACTURES, CONCUSSION, CONTUSION)
1. Differentiate types of head injury by mechanism of injury and clinical manifestations.
a. Hematoma- collection/clotting of blood outside of the blood vessel
b. Hemmorrhage- uncontrolled bleeding. Subarachnoid hemorrhage causes vomiting and HA
c. Concussion- when brain is bounced against hard walls of skull
d. Edema can be cause by any brain injury that causes brain to push against the skull
e. Diffuse Axonal Injury- injury to the brain that does not cause bleeding but damages brain cells
2. Select the appropriate assessment factors for clients experiencing head injury.
i. Assess LOC
3. Distinguish appropriate nursing interventions related to collaborative care, including diagnostic tests and
pharmacological therapies, associated with head injury.
4. Formulate a holistic nursing plan of care, including nursing diagnoses, interventions, rationales, and
evaluation criteria for clients experiencing a head injury. Include preventive, supportive, restorative, and
rehabilitative factors.
B. CLINICAL EXAMPLE: CLIENTS WITH INCREASED INTRACRANIAL PRESSURE RELATED TO CRANIAL
INSULT (EPIDURAL HEMATOMA, SUBDURAL HEMATOMA, INTRACEREBRAL HEMATOMA)
1. Differentiate types of cranial insult by mechanism of injury and clinical manifestations.
i.
2. Select the appropriate assessment factors for clients experiencing cranial insult.
3. Distinguish appropriate nursing interventions related to collaborative care, including diagnostic tests and
pharmacological therapies, associated with cranial insult.
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