IICP

Question 0

Decreased LOC early manifestations

Answer 0

confusion, restlessness, lethargy

disorientation

Question 1

normal ICP

Answer 1

5-15mmHg

Question 2

decreased LOC late signs

Answer 2

comatose with no response to painful stimuli

Question 3

motor impairments early signs

Answer 3

hemiparesis or hemiplegia (paralysis) of contralateral side

Question 4

motor impairments late signs

Answer 4

abnormal responses (decorticate or decerebrate)
flaccidity

Question 5

earliest manifestations of increasing ICP

Answer 5

changes in cortical function

Question 6

cushing’s triad

Answer 6

widening pulse
bradycardia
hypertension

Question 7

contraindicated diagnostic test

Answer 7

lumbar puncture

sudden release of pressure in skull may cause cerebral herniation

Question 8

increase osmolarity of blood

drawing water out of edematous brain tissue and into vascular system for elimination via kidneys

Answer 8

osomotic diuretics

:mannitol

Question 9

initiated if pt has exceeded 15-20mmHg for atleast 10min

dont admin with blood products

Answer 9

mannitol

Question 10

osmotic diuretics interventions

Answer 10

monitor output every hr
monitor for s/s of dehydration
assess for muscle weakness, numbness, tingling, paresthesia
renal function/ electrolytes

Question 11

reduce rate of CSF production
:monitor BP and PR before admin
:monitor renal labs

Answer 11

loop diuretics

:lasix

Question 12

ICP is stable as long as volume added is balanced by volume displaced
3 components must be in equilibrium
CSF, Blood, Brain Tissue

Answer 12

Monroe-Kelly Hypothesis

Question 13

Turning pt interventions

Answer 13

turn pt
wait 2min for ICP to return to prior turning pressure
***If ICP doesnt return, turn pt on back

Question 14

client teaching

Answer 14

avoid coughing, blowing nose, valsalva
avoid isometric (muscle contracting) exercises
maintain head alignment

Question 15

IICP s/s early

Answer 15

altered LOC

Question 16

IICP late s/s

Answer 16

abnormal resp

vasometer response

Question 17

coupe

Answer 17

side of injury

brain rushes forward as head stopped suddenly

Question 18

countre coup

Answer 18

opposite side of injury

brain bouncing back from impact

Question 19

highest ICP can reach during care

Answer 19

25mmHg

***should return to baseline in 5min

Question 20

cushing’s triad

Answer 20

:late sign
:severe hypertension
:widening pulse presure
:bradycardia

Question 21

priority assessment

Answer 21

Resp. Status
brain is dependent on oxygen to maintain function and has little reserve available if oxygen is deprived
brain function begins to diminish after 3min of oxygen deprivation

Question 22

last sense affected by a head injury

Answer 22

hearing

Question 23

pharmacologic intervention that reduces cerebral edema

Answer 23

corticosteroids

Question 24

pharmacologic intervention used at beginning of injury

Answer 24

mannitol