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NCLEX - HURST REVIEW (Neurology) > Intracranial Pressure > Flashcards

Intracranial Pressure Flashcards

1
Q

What are early signs of Increased ICP ?

A
  • Earliest sign would be a change in LOC
  • Speech may become slurred or slowed
  • Delay in response to verbal suggestion (slow to respond to commands)
  • Increase in drowsiness
  • Restlessness with no apparent reason
  • Confusion
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2
Q

What would the earliest sign of Increased ICP be ?

A

A change in LOC

–> a change may be a pronounced as going into a coma or as subtle as a change in attention span (ALWAYS assume the worst)

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3
Q

What are late signs and symptoms of Increased ICP ?

A
  • Marked change in LOC progressing to stupor, then Coma
  • Vital sign changes
    • -> Cushing’s triad (results of pressure on the brain stem)
  • Decerebrate and Decorticate Posturing
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4
Q

Cushing’s Trias requires immediate what? and Why ?

A

Immediate intervention

To prevent further brain ischemia and restore perfusion

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5
Q

What is Cushing’s Triad characterized by ?

A
  • Systolic HTN, with a widening pulse pressure
  • Slow, full, and bounding pulse
  • Irregular respirations
    (look for a change in pattern, like Cheyne stokes or ataxic respirations)
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6
Q

Anytime you have Decerebrate or Decorticate Posturing to painful or noxious stimuli, what does it indicate ?

A

Indicates that the motor response centers of the brain, the mid-brain, and the brain stem are comprimised

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7
Q

How does Decorticate Posturing present ?

A

Towards core/inward

  • Arms flexed inward and bent in toward the body
  • legs are extended (feet inward ?)
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8
Q

How does Decerebrate Posturing present ?

A

Presents with all 4 extremities in rigid extension; WORST

  • Client will be rigid, tight, and burning more calories
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9
Q

Which posture, Decerebrate or Decorticate may indicate more serious damage to the brain ?

A

Decerebrate Posturing

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10
Q

What are Miscellaneous signs of Increased ICP ?

A
  • Headaches
  • Change in pupils and pupil response
  • ## Projectile vomiting
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11
Q

Anytime you have a client with a head injury, if they start complaining of a headache, what do you assume ?

A

Assume that their ICP is going up

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12
Q

In a profound coma, what will the pupils be like ?

A

Fixed and Dilated

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13
Q

Why might Projectile vomiting occur ? and what should you assume ?

A
  • B/c the vomiting center in the brain is being stimulated

- Assume ICP is increasing

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14
Q

What are complications of increased ICP ?

A
  • Brian Herniation (pushes on the brain stem)
    (the herniation obstructs the blood flow to the brain leading to anoxia and then brain death
  • DI and SIADH
    - ADH problems are secondary to others
    -
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15
Q

What are the Treatments for Increased ICP ?

A
  • Maintain oxygenation
  • Maintain adequate cerebral perfusion
  • Keep temperature below 100.4 (38 C)
  • Elevate the HOB
  • Keep head midline so the jugular veins can drain
  • Watch ICP monitor with turning - Monitor VS for Cushing’s Triad
  • Avoid - Osmotic diuretics
    • restraints - Hypertonic saline 3%
    • bowel & bladder distention - Steroids
    • hip flexion - FLuid restriction
    • Valsalva - ICP monitoring devices
    • isometrics
  • No sneezing
  • No nose blowing
  • Limit suctioning & coughing
  • Nursing interventions SHOULD be spaced
  • Monitor glasgow coma scale
  • Barbiturate induced coma
    (if ICP can’t be controlled by other measures)
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16
Q

True or False:

Anytime you do something to your patient, their ICP increases ?

A

True

that’s why nursing interventions should be spaced

17
Q

RULE:

If the Glasgow Coma scale is below is, think __________ ?

A

Intubate

18
Q

Barbiturate Induced comas are used to do what ?

A

Decrease cerebral perfusion

19
Q

How do osmotic diuretics work to lower increased ICP ?

A

Pull fluid from the brain cells and filter it out through the kidneys

20
Q

Why is 3% NS (hypertonic solution) used in the Tx of increased ICP ?

A

Acts like an osmotic diuretic

will pull fluid from the brain to reduce cerebral edema

21
Q

Why might steroids used in the Tx of increased ICP ?

A

To decrease cerebral edema

      --> When a tumor is the cause of the increased ICP
22
Q

What is a type of ICP monitoring device ?

A

Ventricular catheter monitor or subarachnoid screw

23
Q

What is the Greatest risk of having a Ventricular catheter or subarachnoid screw (ICP monitoring device) ?

A

Infection

24
Q

What do you want to make sure is done to decrease the risk of infection in clients with an ICP monitoring device ?

A
  • No loose connections
  • Keep dressings dry
    (bacteria can move through something that is wet much easier than something that is dry)
25
Q

What is the overall goal for Tx increased ICP ? How ?

A
  • Goal is to reduce the increased ICP
  • By…
    • reducing cerebral edema
    • reducing the amount of CSF or blood volume in the brain
26
Q

Why do you Want to maintain oxygenation in clients with Increased ICP ?

A

B/c Decreased oxygen and increased CO2 levels cause Cerebral vasodilation, which increases ICP

27
Q

What don’t you want a client with increased ICP to have in regards to Vital signs and why ?

A

Dont want Hypotension or Bradycardia b/c that would decrease Brain perfusion

28
Q

RULE:

Increased volume = ___________ ? = _________________ ?

A

= Increased CO = Increased brain perfusion

29
Q

Why do want to keep a clients temperature down when they have increased ICP ?

A

B/c an increase in temperature will increased cerebral metabolism and cerebral edema which increases ICP

30
Q

________________ can be used as a treatment to decrease cerebral edema, by decreasing then metabolic demands of the brain ?

A

Hypothermia

31
Q

______________ may also be used in to lower a clients temperature who has increased ICP ?

A

Antipyretics

32
Q

If your turning a client with Increased ICP, and there ICP has not come back down after 15 minutes what does that mean/indicate ?

A

Indicates that they are not tolerating that side very well

NCLEX - HURST REVIEW (Neurology) (7 decks)

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