![]() Which nursing intervention will be included in the plan of care?Ī. A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. Which parameter should the nurse monitor to determine the medication's effectiveness? The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min ANS: A Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/minĭ. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/minĬ. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/minī. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?Ī. "The monitoring system helps show whether blood flow to the brain is adequate." Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage." b. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure."ĭ. "The monitoring system helps show whether blood flow to the brain is adequate."Ĭ. "This type of monitoring system is complex and it is managed by skilled staff."ī. ![]() Which response by the nurse is best for this situation?Ī. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS. The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)?į. The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Excess intravenous fluid administration will also increase cerebral edema. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. ![]() Answer: D Ī patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema. Dehydration can be better avoided with feedings.ĭ. Why are IV fluids being decreased and enteral feedings started?Ĭ. A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Vasoconstrictors are not typically administered in the treatment of ICP. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Answer: A įluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. Maintain physical restraints to prevent episodes of agitation. Administer vasoconstrictors to maintain cerebral perfusion.ĭ. Position the patient in a high Fowler's position.Ĭ. Monitor fluid and electrolyte status carefully.ī. ![]() What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)?Ī. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations. Changes in vital signs (known as Cushing's triad) occur with increased ICP. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)?īradycardia could indicate increased ICP. The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident.
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