Editing Medical-Surgical Nursing – RN Flashcards (section)

== Neurologic and Musculoskeletal ==

;Earliest sign of increased intracranial pressure
:A change in level of consciousness, including restlessness, irritability, or confusion. Cushing triad, which is rising systolic pressure with widening pulse pressure, bradycardia, and irregular respirations, is a late sign of impending herniation.

;Nursing measures that lower intracranial pressure
:Head of bed about 30 degrees, head midline and neutral, avoid hip and neck flexion, prevent Valsalva, cluster care, keep suctioning brief with preoxygenation, control fever and pain, and give osmotic diuretics as ordered. Avoid hypotonic fluids.

;First diagnostic priority in suspected stroke and why
:Noncontrast computed tomography of the head, to distinguish ischemic from hemorrhagic stroke. Thrombolysis saves lives in ischemic stroke and is lethal in hemorrhagic stroke. Alteplase is given to eligible ischemic patients generally within 3 to 4.5 hours of last known well.

;Behavioral differences between right and left hemisphere stroke
:Left hemisphere stroke causes right-sided weakness, aphasia, and slow cautious behavior. Right hemisphere stroke causes left-sided weakness, unilateral neglect, impulsivity, and poor safety judgment, which makes falls a major risk.

;Emergency sequence for autonomic dysreflexia
:Sit the patient upright immediately, loosen constrictive clothing, then find and remove the noxious stimulus, most often a distended bladder or fecal impaction, and notify the provider. It occurs with injury at or above the sixth thoracic vertebra and can cause stroke or death.

;Earliest reliable indicator of compartment syndrome
:Pain out of proportion to the injury, unrelieved by opioids and worsened by passive stretch, with paresthesia. Pulselessness is a very late sign. Keep the extremity at heart level, never above, and notify the provider immediately.