NUR 265 EXAM 3 STUDY GUIDE (100% Correct)

NUR 265 EXAM 3 STUDY GUIDE (100% Correct) This is an all-inclusive guide to NUR 265 EXAM 3 STUDY GUIDE (100% Correct) Cerebral Perfusion Pressure (CPP) o Blood flow required to provide adequate oxygenation & glucose for brain metabolism o Maintenance above 70 mmHg o CPP= MAP-ICP  MAP= (2xD) + S MAP NEEDS TO BE ATLEAST 80 3  Compensation o First Response – CSF is shunted or displaced into the spine (compliance) o Next – Reduction of blood volume in the brain (autoregulation) o As ICP continues to increase cerebral perfusion decreases leading to brain tissue ischemia, edema, vasodilation then acidosis which causes further increases ICP o In edema remains untreated the brain may herniate into spinal canal – death from brain stem compression  Assessment Findings o Changes in LOC – First sign of IICP is declining LOC & includes restlessness or confusion to Stuporous  W/o glucose & 02, brain shuts down. Ex. Pt knew who you were in am & now don’t remember o Headache – Quite environment may have photophobia so keep room lights very low. o Change in speech pattern – Aphasia, Slurred Speech o Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify Dr  Normal is 6 mm. Getting better if going back toward normal from dilated or constricted  Uneven pupils tx as IICP until proven otherwise; pinpoint - brain stem (pons) dysfunction o Abnormal Posturing – Decorticate (flexion) or Decerebrate (extensor)  Decorticate – arms drawn to core, legs straight  Decerebrate – arms straight and stiff, pts rarely survive o Hyperthermia – followed later by hypothermia  When hypothermic – BE CONCERNED, pressure on hypothalamus located next to brain stem o Cardiac & respiratory rate/rhythm changes  Tachy first – Increased HR & RR before brady HR & RR o N/V – Common in IICP o Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia  Late response & indicates severe IICP w/loss of autoregulation, Imminent death  Systolic BP increases bc decreased blood flow to brain  Pressure on Vagus nerve and brainstem = bradycardia  Managing IICP o Elevate HOB 30-45 degrees (unless contraindicated)  If hypotension, elevate HOB where CPP 70 o Maintain head in a midline neutral position o Avoid sudden and acute hip or neck flexion during positioning – Log roll pt o Avoid clustering of care (bath followed by linen change) o Coughing and suctioning increase ICP o Decrease cerebral edema – osmotic diuretics (mannitol) & fluid restriction  Mannitol is hypertonic- pulling fluid into vascular space- will inc. fluid output & monitor BP for HTN  Furosemide used in adjunct to reduce incidence of rebound from mannitol. Helps reduce edema & blood volume, decrease Na uptake by the brain, & decrease production of CSF at choroid plexus. o LOW CSF using intraventricular drain system o Control fever w/antipyretics or cooling blanket – do not allow pt to shiver as will increase ICP  When febrile every cell in body needs more 02 and glucose o Oxygenation – Hyperventilate on a vent to decrease CO2 which causes vasodilation o Reduce cellular metabolic demands – barbiturates (-bital, -barbital) and/or sedation (coma)