Intracranial Pressure and Consciousness Assessment

Glasgow Coma Scale Use

• Used to quickly assess level of consciousness.

Intracranial Pressure (ICP)

• A client with ICP of 12mmHg has an imbalance between brain tissue, blood, and Cerebrospinal Fluid (CSF).
• The best position for a client with increased ICP is with the head of the bed elevated 30 degrees.

Nasal Drainage

• If a client has clear nasal drainage after a head injury, check for glucose.

Altered Level of Consciousness (LOC)

• A rapidly changing LOC is a priority assessment.

Intracranial Pressure Contributing Factors

• Brain tissue, cerebral fluid, and blood.

Increased ICP Risk Factors

• Traumatic brain injury.
• Cerebral hemorrhage.

Early Indicators of Increased ICP

• Restlessness.

Cerebral Perfusion Pressure (CPP) Calculation

• CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP).
• Normal CPP is 70-100mmHg.

Posturing

• Decerebrate posturing (arms and legs extended) indicates increased ICP.

Positioning with Increased ICP

• Avoid flexion of the neck and hips.

Normal Intracranial Pressure

• 15mmHg.

Interventions to Avoid with Increased ICP

• Frequent suctioning to maintain a clear airway.

Cushing's Triad

• Increased blood pressure, decreased heart rate, and decreased respirations.

Spinal Cord Injury Teaching

• Include information about full function limitations for clients and families with T1 spinal cord injuries.
• Target adolescent and young men in spinal cord injury prevention education.

Complete Cord Damage

• Initially incomplete spinal cord injuries may lead to complete damage due to edema, hemorrhage, and metabolite infraction and necrosis of the cord.

Secondary SCI Pathophysiology

• Necrotic destruction of the cord due to hemorrhage and edema.

Spinal Cord Injury Immobilization

• Skeletal traction with skull tongs.

Urinary Function Maintenance in Acute Spinal Cord Injury

• Indwelling catheter.

Neurogenic Shock

• Bradycardia is a clinical modification of neurogenic shock in clients with acute spinal cord injuries.

Autonomic Dysreflexia

• Signs of autonomic dysreflexia includes throbbing headache and increasing blood pressure.
• Assess bladder distension in a client with suspected autonomic dysreflexia.

Risk Factors for Autonomic Dysreflexia

• Spinal cord injury at C7.

Initial Interventions for Autonomic Dysreflexia

• Assessing the patient's blood pressure.

Causes of Autonomic Dysreflexia

• Bladder distension; pressure injury on the scrotum, fecal impaction, urinary tract infection.

Imaging for Spinal Cord Injury

• MRI; gold standard for imaging ligament injury to the spinal cord vertebrae.

Neurogenic Shock Hypotension

• The loss of ability to regulate blood vessel diameter, causing vasodilation.

Spinal Cord Injury Safety Priority

• Maintaining spinal immobilization.

Venus Pooling and DVT Prevention

• Place a pillow under the knees.

Eye Component Assessment

• Spontaneous eye opening, to verbal stimuli, pain, non-testable

Scoring in GCS

• Score and rate and check observable response, for eye movement, verbal response and motor response.
• Record result as a score ranging from 3 (most severe, comatose) to 15 (fully alert and responsive).

Recording with GCS

• For example, eyes not testable (NT)

Supratrochlear Pinch Stimuli

• Use to assess motor response, if bending to touch the stimuli or to move hand towards face.

Parkinson's Disease

• Symptoms, tremor, rigidity, and bradykinesia
• Dopaminergic agents
• Levodopa (precursor of dopamine), that helps to reduce nausea.
• Carbidopa, an agent with levodopa to prevent peripheral tissue metabolism before reaching brain.
• Cautious lifting of toes and wide stance for gait balance in individuals with Parkinson's Disease.

Parkinson's Disease Intervention for Initiating Movement

• Use of canes and walkers, which are prone to injury.

Stroke-like Symptom Assessment

• The "FAST" assessment (facial drooping, arm weakness, speech difficulties, and time) is crucial.
• Impulsive decision-making (inability to make correct decisions) for stroke patients.

Cerebellum Damage After Stroke

• Balance impairment and muscle soreness and pain.

Parkinson's Disease Diagnostic Confirmation

• Medications such as dopaminergic agents.

Falls Prevention in Parkinson's

• Maintaining a wide stance, Cautiously lift the toes when stepping.

Stroke Treatment

• tPA (tissue plasminogen activator) administered within 3-4.5 hours following symptom onset.

Hemorrhagic Stroke

• Contraindicated to administer tPA.

Open-angle Glaucoma

• Aqueous humor cannot drain.
• Peripheral vision loss is typical.

Vertigo vs. Ménière's Disease

• The main difference is their pathology: vertigo is characterized by episodic vertigo, whereas Ménière's disease is characterized by episodic vertigo, hearing loss, tinnitus, and a sense of fullness in the ear.

Otosclerosis Symptoms

• Progressive hearing loss that is typically conductive in nature.

Acute Otitis Media Symptoms

• High-pitched crying, ear pulling.

Otitis Media with Effusion (OME)

• Fluid behind the eardrum without signs of infection is present

Communicating vs. Noncommunicating Hydrocephalus

• Communicating: Impaired CSF absorption.
• Noncommunicating: Blockage in ventricular system.

Intracranial Aneurysm Symptoms

• A sudden, severe headache described as the worst headache of a patient's life.

Intracranial Aneurysm Nursing Intervention

• Maintain calm and quiet environment to reduce blood pressure and stress.