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Medical-Surgical Nursing, 11th Ed., Harding, Kwong, Roberts, Hagler & Reinisch
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56 - Acute Intracranial Problems

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Medical-Surgical Nursing, 11th Ed., Harding, Kwong, Roberts, Hagler & Reinisch | Registered Nurse (RN) School Study Aid

56 - Acute Intracranial Problems
8 Picmonics to Learn | 15 mins
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
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1 min
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
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3 mins
Types of Head Injuries
Open Head Injury
Linear Fracture
Comminuted Fracture
Depressed Fracture
Open Fracture
Basilar Skull Fracture
Closed Head Injury
Coup and Contrecoup
Brain Contusion
Concussion
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2 mins
Increased Intracranial Pressure (ICP) Assessment
Change in LOC
Headache
Cushings Triad
Irregular Respirations
Widening Pulse Pressure
Bradycardia
Projectile Vomiting
Abnormal Pupils
Papilledema
Posturing
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2 mins
Increased Intracranial Pressure (ICP) Interventions
Interventions
Elevate Head Of Bed
Foley Catheter
Mannitol (Osmitrol)
High Dose Barbiturates
Passive Hyperventilation
Dexamethasone (Neoplasm or Infection)
Considerations
Neuro Assessment
Maintain Normal Temperature
Avoid Activities That Increase ICP
Intracranial Monitoring System
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2 mins
Traumatic Brain Injury Assessment
Assessment
Change in LOC
Personality Changes
Amnesia
Increased Intracranial Pressure
Diplopia
Posturing
Location of Injury
Basilar Skull Fracture
Halo or Ring Sign
Considerations
Intracranial Bleeding
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2 mins
Meningitis Assessment
Assessment
Nausea and Vomiting
Fever
Nuchal Rigidity
Severe Headache
Purpura
Seizures
Photophobia
Infants and Young Children
Opisthotonus Position
High-Pitched Cry
Bulging Fontanel
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2 mins
Meningitis Interventions
Drug Therapy
IV Antibiotics
Dexamethasone
Analgesics
Antipyretics
Considerations
Closely Monitor for Increased ICP
Bed Rest
Preventative Vaccinations
Droplet-Airborne Precautions
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2 mins

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