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82 Cards in this Set

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Early sign of ICP
Irritability
What is the first thing to compensate when hyou have increased ICP
Promotion and reabsorption of CSF
A patietn presents with his arms rigid and flexed, he ahs hyperflexion ofhis upper extremities and hyperextension of his lower extremities. What kind of posture is this
Decorticate
A patient presents with BP of 137/90 and an ICP of 20 what is the patient's ICP
85.6
A patient presents with increased ICP and has a widened pulse pressure, decreased HR and abnormal respirations. What interventions would the nurse anticiapte?
Fluid restriction, mannitol, and intubtion
What is a late indicator of increased ICP
incrasing blood pressure and bradycardia
What warly signs should the nurse observe as an early indicator of increasing ICP
Declining level of consciousness
A client is transferred to ICU after a craiotomy. What should the nurse do to reduce the client's risk of developing increased ICP?
Administer stool softeners as prescribed
What is not a nursing intervention to prevent an increase in ICP
maintaining a well-lit room
Drug of choice for decreasing ICP
mannitol
Early sign of serious impairment of brain circulaation related to increasing ICP
lethargy and stupor
Initial compensatory vital sign changes with increased ICP
Respiratory rate irregularities, slow, bounding pulse, increased systemic blood pressure.
For a steady state, an increase in one component must be compensated for by an equal decrease in the other components to maintain a constant volume and pressure in the box
Monroe-Kellie doctrine
Nursing care activities for a patient with increased ICP
use of a cervical collar
teach patietn to exhale when being turned to avoid valsalva maneuver
Avoid activities that interfere with venous drainage of blood from the head
How should mannitol be given
give as a bolus
How does mannitol work
draws fluid from brain cells into the bloodstream promoting cerebral cell dehydration
How does mannitol improve oxygen delivery
it expands circulating volume and blood viscosity, and therefore increases CBF and O2 delivery
A patient presents with transient symptoms of N/V and personality changes. What stage of intracrania hypertension would the nurse suspect the patient is in
Stage 1
A patient is to be on IV therapy for increased ICP. What solution should the nurse anticipate hanging
Normal Saline
Cushing's triad is a result of pressure on what area of the brain
the brain stem
An increase in ICP is critical at
30 mmHg
Compensation for increases in ICP include
CFS regulation
Autoregulation of blood flow
Metabolic regulation fo blood flow
The nurse wants to keep a normovolemic state in the patient in order to
increase CPP and decrease ICP
You walk into a patients room and addess the following: a CPP between 60 - 100 mmHg, decrease cerebral oxygen, increase CO2, and hypothermia. You realize that the patient is
metabolically regulating his blood volume
What is a normal ICP value
0-20
Longer term treatments of ICP include the following
Administration of NS
Admin of stool-softeners
Seizure precautions
Mannitol increases
oxygen delivery to the brain
Stage 1 of ICP
subtle changes in LOC
trouble remembering
personality changes
drowsiness
HA esp in AM
N/V
Stage 2 of ICP
present consisten s/s
systemic vasoconstriction to selevate systolic BP
Neuronal oxygenation compromised
Stage 3 of ICP
Compensatory mechanisms are exhausted
Dramatic increase in IPC
Changes are occuring rapidly
Stage 4 ICP
Brain herniation occurs
blood supply further compromised fcausing further ischemia and hypoxia in herniated tissue and displaced brain tissue.
Effects of Stage 4 ICP
Hemorrhages
obstructive hydrocephalus
Respiratory and or cardiac arrest due to brain stem herniation
How does brain herniate?
Brain tissue is shifted from higher pressure to lower pressure compartment
Types of Brain Herniation
Uncal is most common
Compression of CN III
Cerebral ischemia
Hemiparesis
Cheyne Stokes
Cheyne Stokes - hyperventilation that graduallly diminishes to apneic periods followed by return to hyperventillation
Late Symptoms of ICP
Rapid deterioration of condition
New onset of seizures
Decorticate or decerebrate posture
Glascow Coma Scale of < 8
Hypotension right before death
Respiratory changes
Ataxic breathing
chaotic ventilations
Central neurogenic hyperventilation
Continuous rapid and deep breathing
Apneustic Breathing
prolonged inspiratory phase followed by apnea (intubate)
What is CPP
A measurement used to determine brain perfusion of cerebral blood flow and blood volume
What is the range for CPP
> or equal to 70 to maintain brain perfusion
Calculation for CPP
CPP = MAP - ICP
Calculating MAP
Diastolic + 1/3 (Systolic - diastolic)
When chould ICP be controlled
When CPP falls below 70 or ICP is greater than 20
What is more important - maintenance of CPP or control of ICP
Maintenance of CPP
Fentenyl
Opiate used to keep pts with increased ICP quiet so pressure is lower
Methods ot decrease ICP
IV fluid therapy (fluid restriction)
Mannitol - shrink the cells
Ventilation (last resort and short term
Sedation and anesthesia
Changes in VS as ICP rises
Sysstolic BP increases
Pulse decreases
Temperature increases
Respirations abnormal
VS as client approaches brain death
hypotension
cardiac and ventilation collapse occurs
Cushings Triad
Compensatory mechanism that tries to raise CPP even though ICP is increasing
What is Cushings Triad
Widened pulse pressure
Decreased heart rate
abnormal respiration
What does Cushings triad reflect
apressure on the brain stem
Critical situation
Ventilation for ICP
Maybe venvilator to bring CO2 to normocapnia levels
Hyperventilation used for only a short time to lower pressure
Drawback of hyperventilation
lowers ICP and CPP
IV Fluid Therapy for ICP
NS or lactated ringers only.
Keeps up CPP and does not increase ICP
What does hypotonic solutions do for ICP
Decreases plasma osmolality
Mannitol for ICP
Effects immediatelya fter bolus administration (15-30 minutes)
Acute reduction of ICP
Why is it important to establish renal status before administering mannitol
it is excreted in the urine
NDX for ICP
Altered cerebral tissue perfusion
Ineffective respiratory function
Ineffective airway clearance
risk for aspiration
Risk for infection
Risk for injury
Hyperthermia
Total incontinence
Constipation
Artificial tears
for absent corneal reflex
Osmotic Diuretic
mannitol
Lasix
to rid the body of extra fluid
Decadron
decrease inflammation
4 mg IVP q6h
Dilantin
prevent seizures
Tylenol
Fever - is it from infection or increased ICP
Antibiotics
Infection
NI
Assess VS
Maintain patent airway
Preoxygenate with 100% O2 when suctioning
HOB 30-45 degrees
neck in nutral midline position
discourage coughing
no valsalva movement
NI
seizure precations
Strict I/O
Restrict fluids
Mitts on hands to prevent IV pull out
Critical Care Monitoring
ICP monitoring
Barbituate Coma
Sedatives
Therapeutic endpoints
ICP <20
CPP 70-100
Stable VS
Resolution of intracranial mass effects or midline shifts
Failure of CARE
Uncontrolled ICP
Cushing's triad
CPP < 70
Brain Herniation
Hyperthermia
Respiration or cardiac irregularities
Sepsis
Progressive pulmonary dysfunction
Uncontrolled hypotension
ICP
Increased BP, Decrease pulse, decreased respirations
Shock
Decreased BP, incrased pulse, increased Respirations
S/s of ICP
Changes in LOC, unequal pupils
Papilledema (CNII)
HA upon waking
Vomiting
Decreased sensory/motor function
ICP pressure in the head from force of
Brain (tumor, edema, abscess)
CSF (flow, obstruction, hydrocephalus)
Blood (flow, bleeding, clots)
Monroe-Kellie Doctrine
increase in one component must be compensated for an equal decrease in the other components to maintain a constant volume
What temporarily increases ICP
Coughing, sneezing, valsalva
How can you measure ICP
Transducer in lateral ventricle, subdurally or within brain tissue
Compensatory mechanisms for ICP
CSF regluation
Autoregulation of blood flow
Metabolic regulation fo blood flow
CSF Regulation
Compensates until the pressure gets too high and the compensations are no longer effective
Autoregulation
Decreased CPP with increased ICP. If ICP remains high then cerebral blood volume and CPP is reduced by vasoconstriction
Metabolic regulation of blood volume
Hyperventilation decreases metabolites and increases cerebral oxygen, no vasodialation, decreased CPP