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11 Cards in this Set
- Front
- Back
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What are the indications for neurological observations?
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- fall
- head injury - delirious - post neurosurgery - monitoring conscious state |
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Why is it so important to take vital signs with a neurological assessment?
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- Vital signs can correlate with neurological state.
- Monitor for raise in ICP - HR decrease and BP increase indicate raised ICP. (Initially HR increases) |
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What is a GCS and what does it tell us about the patient?
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Glascow Coma Scale = level of response and conscious state
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What are the components of a GCS?
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- Eye response
- Verbal response - Motor response |
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Why is pupil assessment so important?
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- Can indicate swelling of the optic nerve
- Can indicate what part of the brain is affected - Monitor for different sizes and response to light |
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What is the Munroe Kellie hypothesis?
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- Skull is a rigid vault
- blood volume is constant - venous blood in = aterial blood out - brain parenchyma is nearly incompressible |
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How should a patient be positioned after neurosurgery?
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30 degrees
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What post-op complications can occur for a patient who has had neurosurgery?
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- bleeding
- infection - nerve and tissue damage - swelling - paralysis - increased ICP |
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What can cause a rise in ICP in these patients and what nursing measures should we implement?
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What can increase ICP:
- Oedema - Swelling - Electrolyte imbalance - Bleeding in the brain - Hyperthermia Nursing Measures: - MET call - notify MO - ensure patient is at 30 degrees - if hyperthermia, attempt to decrease body temperature - attain medication orders - monitor patient |
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What medications are given to control raised ICP and how do they work?
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- IV dexamethasone: osmotic effect + reduce brain swelling
- Osmotic diuretics: reduce oedema - Hypertonic saline: reduce oedema |
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Can you list the complications that can occur if the patient's unconscious state is prolonged?
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- Muscle wasting
- pressure ulcers - chest infections - pulmonary embolism - DVT - UTI |
