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