QUIZ #1 FINALS: ICP Flashcards

Question

→ Motor Impairment ▪ Late: D__ or D__ positioning flaccidity. ✔ ____ = diencephalon is damaged (thalamus, epithalamus, and hypothalamus). ● The hypothalamus regulates pleasure sensations, emotions, thirst and hunger sensations, and sexual arousal. ✔ ___ = brainstem is damaged ✔ D__ and D__ posturing reflects significant brain dysfunction and are frequently associated with increased ICP and early herniation

Answer 1

Decorticate or Deccerabrate Decorticate Decerebrate Decorticate AND Deccerabrate

Answer 2

Pyramidal Decussation

Answer 3

→ Widened Pulse Pressure (late manifestation)

Answer 4

✔ Use elastic compression stockings because they compress the muscles, causing the veins to contract and aiding in the push of blood toward the heart. ✔ Perform ankle pumps because these cause muscle contractions, which promote venous return to the heart. ✔ Perform passive exercises to promote venous return and prevent pooling of blood in the lower extremities. ✔ Encourage increased fluid intake to maintain adequate hydration, which helps prevent dehydration and reduces the viscosity of blood, thus preventing clot formation. ✔ Reposition the patient every 2 hours to prevent pressure ulcers and promote circulation, aiding in venous return. ✔ Never apply a pillow under the knees because it can cause pressure in the popliteal vein thus blood accumulation happens.

Answer 5

→ Cushing’s Triad (late manifestation)

Answer 6

→ Place the patient in a semi fowler’s position or sim’s position. → Any activity that suddenly increases the BP or obstructs venous return is avoided. ▪ Placing the patient in a 90-degree position because the blood in the lower extremities has a hard time returning to the right side of the heart due to hip flexion, which can lead to blood viscosity and thrombus formation. ▪ smoking - vasoconstriction ▪ drinking alcohol ▪ Valsalva maneuver (e.g., during bowel movements, pushing up in bed, reaching for an item on a bedside table that is out of reach, prompting the patient to take a deep breath and hold it) ▪ acute flexion or rotation of the head and neck ▪ pushing or pulling ▪ Sneezing or Coughing ✔ Advise the patient to avoid eating foods that can irritate their pharynx, such as popcorn, cornick, peanuts, crackers, to prevent coughing. ✔ Advise the visitors of the patient to avoid bringing flowers to prevent the patient from sneezing. ✔ Clean the room with a damp cloth or vacuum to prevent the patient from sneezing. → Place the patient on bedrest in a quiet setting. → Avoid the flexion, extension, and lateral rotation of the head and neck. → Avoid extreme hip flexion because the blood in the lower extremities has a hard time flowing to the right side of the heart. ▪ increases intrathoracic pressure and interferes with venous drainage → Assist the patient to turn and move self in bed; instruct the patient to exhale while turning or pushing up in bed. → Maintain patent airway and adequate ventilation of oxygen to prevent hypoxemia and hypercarbia. ▪ Hypercarbia can cause vasodilation, which can further increase ICP. ▪ The bronchi should be patent and not partially obstructed because it will reduce the oxygen supply to the brain. ✔ Turn the patient every 2 hours to mobilize the mucus. ✔ Humidify the air to facilitate the patient's ability to cough out the mucus. ✔ Implement postural drainage. ✔ Increase fluid intake to thin the mucus if cerebral edema has been treated; the patient has stopped mannitol, indicating the absence of edema. ✔ Allow the patient to ambulate if paralyzed; otherwise, place them in a wheelchair. ▪ If obstruction occurs, suction the patient, but consider it as the last intervention due to its invasiveness. ✔ When suctioning a patient with increased ICP: suctioning can increase ICP, administer 100% oxygen inhalation for 5 minutes. ✔ Insert the catheter and release to suction only for 10 to 12 seconds, and rotate it as you withdraw. ✔ Repeat after 1 to 2 minutes, limiting suctioning to two passes. ✔ After removal, immediately oxygenate the patient. → Plan the patient care activities and nursing interventions. ▪ Avoid unnecessary additional disturbances. ▪ Allow patient up to 1 hour of rest between activities as frequently as possible. ▪ Engaging the patient in various activities can increase ICP, including sponge baths, turning, checking of vital signs, and changing linens. Allow the patient to rest for 15 to 20 minutes between activity periods. → Maintain Normothermia with external cooling or heating measures. ▪ If the temperature increases by just one degree Celsius, it elevates the brain's metabolism by 10%. Increased metabolism results in the production of carbon dioxide. Elevated levels of CO2 cause vasodilation, leading to further increase in ICP. ✔ tepid sponge bath ✔ cool the room ✔ do not wrap the patient with blanket ✔ light clothing → With physician’s collaboration, control seizures with prophylactic and PRN anticonvulsants. ▪ Seizures can greatly increase the cerebral metabolic rate. ✔ side rails up ✔ pillows should be ready ✔ use dim lights so that they can sleep → Pleasant sensations such as: ▪ stroking the arm or forehead ▪ listening to music the patient likes

Answer 7

- limit the visitors of the patient - place the patient in a private room if they can afford, if not use curtains to provide privacy - turn off the televisions - encourage the family of the patient to report if - choose a room away from the noisiest area in the hospital (nurse’s station, elevators)

QUIZ #1 FINALS: ICP Flashcards

(31 cards)