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19 Cards in this Set
- Front
- Back
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What is the main cause of increased ICP? |
Traumatic head injury |
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What are the signs and symptoms of increased ICP? (Remember “mind crushed”) |
1) Mental status changes (earliest sign) 2) Irregular breathing: cheyne stokes 3) Nerve changes to optic and oculomotor (e.g. double vision, increase/decreased/unequal pupils) 4) Decerebrate or decorticate positioning 5) Cushings triad 6) Reflex and Babinski 7) Unconscious 8) Seizures 9) Headache 10) Emesis 11) deterioration of motor function |
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What is the analogy for remembering nursing interventions for ICP? |
Pressure |
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What does P stand for in nursing intervention? |
Position HOB at 30-35 degree angle (Fowlers) |
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What does the R stand for in nursing interventions? |
Respiratory (prevent hypoxia and hypercapnia) |
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What does E stand for in the pressure nursing intervention analogy? |
Elevated temperature prevention |
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What does the first S In the pressure nursing intervention analogy stand for? |
System to monitor = neurological status with Glasgow coma scale |
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What does the second S stand for in the pressure nursing intervention stand for? |
Straining activities avoided e.g. avoid coughing, sneezing, vomiting etc. |
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What does the U stand for in the pressure nursing intervention analogy? |
Unconscious patient care (reposition, listen to lungs sounds, avoid over sedating) |
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What does the R stand for in the pressure nursing intervention analogy? |
Rx (prescription medication) - barbiturates to decrease brain metabolism and blood pressure - anti hypertensives for increased blood pressure - vasopressors and IVF for decreased blood pressure - anti convulsants |
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What does the E stand for in the pressure nursing intervention analogy? |
Edema management (with hyperpsmotic medications) |
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What would severe Glasgow come scale reading? |
3-8 |
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What would be a moderate Glasgow coma scale score? |
9-12 |
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What would be a good Glasgow coma scale score? |
13-15 |
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What causes a fixed dilated pupil and unequal pupil sizes in increased ICP? |
Compression of the 3rd cranial nerve |
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What is the cushings triad? |
1) irregular respiratory pattern 2) widening pulse pressure and increased systolic blood pressure 3) bradycardia |
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What might a positive babinski reflex indicate in an adult?? |
Pyramidal tract dysfunction |
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Explain cheyne stokes breathing? |
Rapid, shallow and irregular respiration’s |
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Why is fowlers position indicates in patients with ICP? |
It facilitates venous drainage from the brain and decreases ICP |
