Exam 5 - Increased Intracranial Pressure

Front 1

signs of increased ICP

Back 1

change in LOC (early sign)
papilledema (swelling of optic nerve) won't see it but pt will have huge blind spot
unequal pupils initially

Cushings triad - ↑systolic BP, decr pulse, decr resp pattern
Vomiting
Can’t understand their speech

Front 2

signs of IICP is opposite of what other condition

Back 2

shock

Front 3

things that can increase ICP

Back 3

coughing
bending over
straining
sneezing
being emotionally upset
certain smells (perfumes)
lack of O2
too much CO2

Front 4

priorities of care for IICP

Back 4

• Maintain airway – anything in mouth?
Assess for abdominal distention – fluid in abdominal cavity can raise ICP – diuretics to reduce fluids, steroids (Solu-medrol), High saline IV (3%) but fluid follows sodium
• Use narcotics carefully due to affect of altering LOC and depressing respirations (morphine & fentanyl are short acting narcotics)
• Accurate I&O and weights
• Prophylactic antiseizure meds – not uncommon for seizure to occur
• Pituitary gland injury can cause SAIDH or diabetes Insipidus

Front 5

clinical do's & don'ts to prevent transient increases in ICP

Back 5

do: tell pt what you are doing before doing it
maintain patent airway
suction secretions only if necessary
elevate HOB 30 to 45 degrees
avoid head to shoulder or chin to chest
if pt can follow directions ask her to exhale when turning (more relaxed when exhaling)
prevent shivering
DONT's:
don't perform multiple nsg activities w/in short time
don't allow pt to grip side rails

Front 6

formula to determine CPP

Back 6

MAP minus ICP
ex: BP 92/50
MAP=92+100/3=64
18 = ICP
MAP-ICP= 46