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52 Cards in this Set
- Front
- Back
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Shaken Baby has what type of cerebral damage?
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subdural hemorrhage
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Most important indicator of neurological status is....
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level of consciousness
#1 sign |
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What would a chance in LOC look like?
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sleepy at times they normally are not
restless, irritability changeing moods, can't get comfortable |
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What are the two scales to use to test for brain injury or LOC?
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AVPU
Glasgow Coma Scale |
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What does AVPU stand for?
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alert
verbal pain unconscious/unresponsive we are moving down this scale....like awake alert, if no they do they respond to VERBAL, if no, then do they respond to PAIN - sternal rub for 30 seconds, etc |
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What are the three main assessments for the glasgow coma scale?
What score would be good a lower or higher score? |
eye opening
verbal response motor response a higher score is better. Best score is 15, if you are below 8 you have severe injury |
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If pupils are unequal, what does this signal?
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increased ICP, impending brainstem herniation
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If pupils are pinpoint, what does this signal?
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pons damage
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IF pupils are dilated (large), what does this signal?
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hypoia, atropenic
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What does a PET do?
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radioactive dye, IV, evaluates blood flow to brain
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What does an EEG do?
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measures brain activity
not going to hurt |
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What is normal glucose in CSF?
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35-75
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W is normal protein in CSF?
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15-45
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Pupils unequal +
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impending brainstem herniation
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What is glucose level in bacterial meningitis?
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low, b/c bacteria is earing it. Protein is elevated in bacterial meningitis
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What three things can cause intracranial pressure to increase?
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brain swelling - trauma, infection tumor
blood - trauma, hematoma CSF - increased production or reduced absorption |
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Because infants can accomodate increased ICP, the nurse knows to monitor the following sites:
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- head circumference
- buldging fontanelles also, a high pitched cry, inconsolability, dilated scalp veins, poor feeding |
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What is cushing's triad?
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a late sign of increased ICP
1. increased systolic blood pressure and widened pulse pressure 2. bradycardia 3. irregular respirations |
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What do sunset eyes mean?
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pressure on optic nerve pushes eye down
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What are the early signs of increased ICP?
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dizziness
change in v/s headache, diplopia, n/v pupils not as reactive, or equal sunsetting eyes seizures restlessness |
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What are the late signs of increased ICP?
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serious LOC changes
pupil changes (fixed/dilated/unequal) Cheyes Stokes resp Cushings Triad |
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What are the jaws of death?
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widened pulse pressure
bigger difference between systolic and diastolic are a symptom in cushings triad |
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Coup injury is...
Contrecoup injury is... |
direct blow to head
secondary impact |
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brain injury is caused by
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shearing forces tear small blood vessels and injure nerve tissue
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Primary injury is caused from ________ _________ while the secondary injury is caused by the response of the brain to the trauma and includes symptoms like:
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direct trauma (fracture of skull)
secondary response is edema, hypoxia, infection, increased ICP |
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What is a pediatric concussive syndrome?
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injury to brain stem
kid under 3 no LOC, pale, shaki, vomit |
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What is post concussive syndrome?
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child and adult. changes include school performance, personality, headache, dizziness, fatigue (can last up to 6 months)
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What is second impact syndrome?
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second concussion b/4 completely recovering from 1st - cummulative effects
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What is a basilar skull fracture?
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middle back of brain
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What are the manifestations of a basilar fracture?
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csf leak from nose - not mucus, has glucose
racoon eyes battle's sign (mastoid bruise) |
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You make sure that a basilar fracture does not have the following treatment:
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no ng tubes
no nt suction no nose blowieng |
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Fast arterial bleed
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epidural hemorrhage
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Venous bleed
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subdural hemorrhage
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Birth trauma, falls, shaken baby syndrome
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subdural - ACUTE, symptoms may not occu until 48 to 72 hours
CHRONIC - symptoms take weeks to develop |
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Epidural hemorrhage happens to ....
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kids older than 4
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Meningitis is an infection of the ___________________. Its causative agent is ________________.
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meninges
bacterial usually |
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What is popular meningitis bacterial?
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Meningococcal N. Meningitidis
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What is a presenting integumentary manifestation with N. meningitidis?
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petechial rash
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What can cause meningitis?
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birth canal flora
secondary response to primary infection else-where (sepsis, otitis, sinusitis, cellulitis) |
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What are symptoms that make you suspect meningitis?
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hypothermia (in infant)
fever poor feding high pitched cry (ICP) irritability sleeplessness vomiting apnea headache photophobia petechial rash |
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What is nuchal rigidity?
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stiff neck
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What is opisthotonic positioning?
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seal position, done to relieve pressure on neck
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What is Kernig's test?
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knee bent, extend it straight, pain positive
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What is Brudzinski's test?
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head will come up if you pul up knee
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What is main diagnostic of CSF?
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protein increased
glucose decreased WBC over 100 in CSF |
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What are nursing interventions for meningitis?
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start abx before culture return
monitor for increased ICP, shock quiet, dark room, comfort measures droplet precautions |
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What do you do to help with a seizure?
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protect from injury
maintain airway, turn on side, o2 and suction note onset, and recovery, time it lasted |
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For Status Epilepticus - seizure that lasts more than 30 minutes, what is treatment?
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Dilantin
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What do you have to remember about Dilantin (all on test)?
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shake it
Mix with NS, NEVER D5 Never give it faster than 50mg/min |
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Think about dilantin equation for test. What is formula?
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amount divided by x
50 devided by 1 minute ratio propritoin |
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In child with Arnold Chiari II or hydrocephalus, what is placed to help?
What are two main concerns of complications? |
vp shunt
infection and increased ICP |
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What is post op care for VP shunt?
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lay flat and gradually raise HOB
measure head watch for infection |
