PBDS Med-Surg Study Guide QUESTIONS WITH COMPLETE SOLUTIONS

Neuro Correct Answer: Increased ICP, Hemorrhagic Stroke, Ischemic Stroke Increased ICP: Clinical Manifestations Correct Answer: - Slow bounding pulse, irregular respirations. - Changes in LOC, confusion, drowsiness, stupor, coma - Double or blurred vision, headache, N/V, photophobia, fixed or dilated pupils, decerebration - Decreased motor function - Late Signs: Cushing's Triad (widening pulse pressure, bradycardia, tachypnea) Increased ICP: Causes Correct Answer: Tumor, cranial abscess, intracranial bleed, cerebral hypoxia, hypertension, hydrocephalus, head trauma. Increased ICP: Diagnostic Studies Correct Answer: Serum electrolytes, serum osmolarity, cerebral angiography, CT scan, MRI, PET to r/o physiological cause, transcranial doppler Increased ICP: Immediate Interventions (15mins) Correct Answer: - Wash hands, don gloves - Assess airway patency and breathing - Assess VS - Assess GCS - Notify MD of findings STAT - Provide high-flow O2 with NRB - Administer diuretics as ordered - Assess meningeal signs - Elevate HOB - Keep head in neutral alignment - Avoid flexion of neck or hips - Minimize environmental stimuli - Document patient's status, phone call to MD, and MD's response Increased ICP: Urgent Interventions (1hr) Correct Answer: - Assess neuro status - Assess cranial nerves - Assess cardiac rhythm, O2 saturation. Increased ICP: Ongoing Interventions (within shift) Correct Answer: - Maintain SBP within parameters ordered by MD - Limit suctioning - Maintain SaO2 at 100% - Monitor ABGs and electrolytes - Document all findings Increased ICP: Anticipated Orders Correct