ICP Increased Intracranial Pressure Flashcards
(17 cards)
What is the normal intracranial pressure range?
5 to 15
What are the common causes of ICP
Trauma
Hemorrhage
Edema
Tumors
What should the nurse assess
The LOC (decrease as ICP increases)
What is the earliest sign of ICP
Decreased LOC
The adult client will often appear (ICP)
Restless
Agitated
Reporting headaches
What are the signs of iCP in babies
Bulging fontanelles
Strabismus
Vomiting
Seizures
High pitched cry
Lethargy
Client with ICP may report
Projectile vomiting without nausea
How will the vital signs appear with ICP
BP - up
Temp - Up
Respiration - Up then down
Heart rate - Up
What is widening pulse pressure and how it is related
Systolic goes up, diastolic goes down and they get further and further apart
Indicates deteriorating cardiovascular health
What is Cushings Triad
Three things
Widen pulse pressure
Cheyne stokes respirations
Bradycardia
Always initiate what with ICP
Seizure precautions
Late signs of ICP
Unilateral pupil dilation
Hypertension or hypotension
Bradycardia
ICP head of bed elevated
10 to 30 degrees to promote jugular venous outflow
Medications for ICP
Anticonvulsants
Antihypertensives
Corticosteroids
Diuretics
Teach the client not to do what with ICP
Strain, cough or sneeze - this will increase ICP
Nursing interventions would be to what with ICP
Decrease stimuli
Maintain temp
Limit fluids
Monitor in and out
ICP nursing Priorities
Establish baseline neurological status
Cerebral metabolic rate increases with temp - keep temp normal
Deo not give meperidine hcl as it will increase intracranial pressure
