NUR 265 EXAM 3 || QUESTIONS AND ANSWERS.
damage to the brain caused by an external force correct answers what is a tbi
GCS of 13-15, difficulty to concentrate, (concussion), loss of consciousness up to 30min correct
answers what is a mild TBI classified as ?
gcs of 9-12, loss of consciousness 30min-6hrs correct answers what is a moderate tbi classified
as?
gcs 3-8, loss of consciousness more than 6hrs correct answers what is a severe tbi classified as?
open-skull is fractured
closed-blunt force trauma, integrity of skull isnt compromised
closed is worse correct answers difference between open and closed tbi
Brain Hernitation-cheyne stokes breathing, hemodynamic instability, fixed and non-reactive
pupils correct answers what is the complication of a tbi and IICP and what is its symptoms?
1. mannitol-via iv filter, used until serum osmolarity reaches 310-320
2. furosomide
3.fentanyl- decrease pain and restlessness
4. proprofol and midazalam-sedation
5.lidocaine- to surpress cough reflex correct answers what are the medications used for a TBI?
used in a TBI
pt core temp is reduced to 89.6-93.2 for 24-48hrs post primary injury, decreases cellular demands
correct answers what is therapuetic hypothermia ?
,1.assess ABC's
2.implement spine precautions
3.)vital signs
4.)neuro assessment
*report any GCS point change of 2 or more correct answers assessment for TBI
-pt supine
-spine and head in neutral midline position
-bed rest
-NO neck of hip flexion
-NO thoracic/lumbar flexion
-manual control of cervical spine when C collar is removed
-log roll correct answers what is included in spine precautions?
-vitals Q1-2hrs
-if intubated provide 100%o2 before and after every suction
-maintain Pao2 80-100
-AVOID hyperventilation in the first 24hrs
-implement seizure precautions
-maintain hazard free environment
-reorient pt to person, place and time
-always re introduce yourself when you go in pt room
-keep explanations short and simple
- collab with rehab for cognitive rehab correct answers nursing interventions for TBI
-acetaminophen Q4hrs as needed for headache
, -avoid sedatives and alcohol for at least 24 post TBI
-AVOID strenuous activity for at least 48 hrs
-keep follow up appts
-call 911 if :
-seizure -increased weakness -servere of worsening HA -slurred speech -blurred vision -clear
drainage from ears or nose -unequal pupils - increased sleepiness correct answers pt educations
for TBI (mild)
- dazed and confused
-inability to concentrate
-amnesia
-mental fog
-irritable
-N/V
-gait changes
-visual changes
dizziness
-sleeping more or less
-trouble falling asleep correct answers symptoms of mild TBI
10-15mm hg correct answers what is the normal range for ICP?
change in LOC correct answers earliest sign of IICP
-loc changes
-servere HA
-aphasia
-vomiting
damage to the brain caused by an external force correct answers what is a tbi
GCS of 13-15, difficulty to concentrate, (concussion), loss of consciousness up to 30min correct
answers what is a mild TBI classified as ?
gcs of 9-12, loss of consciousness 30min-6hrs correct answers what is a moderate tbi classified
as?
gcs 3-8, loss of consciousness more than 6hrs correct answers what is a severe tbi classified as?
open-skull is fractured
closed-blunt force trauma, integrity of skull isnt compromised
closed is worse correct answers difference between open and closed tbi
Brain Hernitation-cheyne stokes breathing, hemodynamic instability, fixed and non-reactive
pupils correct answers what is the complication of a tbi and IICP and what is its symptoms?
1. mannitol-via iv filter, used until serum osmolarity reaches 310-320
2. furosomide
3.fentanyl- decrease pain and restlessness
4. proprofol and midazalam-sedation
5.lidocaine- to surpress cough reflex correct answers what are the medications used for a TBI?
used in a TBI
pt core temp is reduced to 89.6-93.2 for 24-48hrs post primary injury, decreases cellular demands
correct answers what is therapuetic hypothermia ?
,1.assess ABC's
2.implement spine precautions
3.)vital signs
4.)neuro assessment
*report any GCS point change of 2 or more correct answers assessment for TBI
-pt supine
-spine and head in neutral midline position
-bed rest
-NO neck of hip flexion
-NO thoracic/lumbar flexion
-manual control of cervical spine when C collar is removed
-log roll correct answers what is included in spine precautions?
-vitals Q1-2hrs
-if intubated provide 100%o2 before and after every suction
-maintain Pao2 80-100
-AVOID hyperventilation in the first 24hrs
-implement seizure precautions
-maintain hazard free environment
-reorient pt to person, place and time
-always re introduce yourself when you go in pt room
-keep explanations short and simple
- collab with rehab for cognitive rehab correct answers nursing interventions for TBI
-acetaminophen Q4hrs as needed for headache
, -avoid sedatives and alcohol for at least 24 post TBI
-AVOID strenuous activity for at least 48 hrs
-keep follow up appts
-call 911 if :
-seizure -increased weakness -servere of worsening HA -slurred speech -blurred vision -clear
drainage from ears or nose -unequal pupils - increased sleepiness correct answers pt educations
for TBI (mild)
- dazed and confused
-inability to concentrate
-amnesia
-mental fog
-irritable
-N/V
-gait changes
-visual changes
dizziness
-sleeping more or less
-trouble falling asleep correct answers symptoms of mild TBI
10-15mm hg correct answers what is the normal range for ICP?
change in LOC correct answers earliest sign of IICP
-loc changes
-servere HA
-aphasia
-vomiting
