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16 Cards in this Set
- Front
- Back
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The head is a rigid box containing what 3 things?
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Brain, Blood, CSF
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What is normal ICP?
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5-15 mm Hg
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What is the Monroe Kellie Hypothesis state?
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An increase in any 3 components will decrease one or both components and will cause an increase in ICP
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How does the head compensate for increased ICP?
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Displacement of brain tissue, compression of blood vessels (decreasing blood volume), pushing of the CSF from cranium to spinal cord
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What is the difference between a rapid increase and slow increase of excess volume accumulation?
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With a rapid increase there is only a limited time to compensate, but with a slow increase compensatory mechanisms have time to work. (When compensatory mechanisms fail pressure rises rapidly)
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What factors influence ICP?
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Arterial pressure, venous pressure, intra-abdominal and intra-thoracic pressure, posture, oxygenation, acid-base status, body temp.
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How does body temperature and acid base affect ICP?
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Acidosis=dilated cerebral vessels=increased ICP Alkalosis=constricted cerebral vessels=decreased ICP Hypothermia=decreased CBF=decreased ICP Hyperthermia=increased CBF=increased ICP
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What are the early S/S of increased ICP?
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Change in behavior or LOC, vomiting w/o nausea, cheyene-stokes respirations (must monitor apneic periods), motor changes (weakness, pronator drift test, posturing i.e. decerebrate or decorticate)
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What are the middle S/S of increased ICP?
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Headache (not from trauma), decreased visual acuity, diplopia, blurring, papilledema
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What are the late S/S of increased ICP?
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Unequal pupil sizes (sluggish to fixed), decreased pupil reaction to light, Cushing’s Triad (bradycardia, systolic hypotension or widening pulse pressure, abnormal breathing patterns
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What are the functions and characteristics of CSF?
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Functions as cushion for the brain and spinal cord--- CSF is clear, colorless, odorless, has glucose, free of RBC’s, normal volume at one time 100-150 mL, 500 ml’s produced daily, produced 20-30 mL/hr (if less than w/drain probably clotted), if not reabsorbed leads to hydrocephalus
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What are the types of ICP monitors?
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Intraventricular or ventriculostomy (most invasive, greatest risk for infection, dressing needs to be dry and occlusive at all times), Subarachnoid bolt, epidural catheter
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Where is the stopcock positioned on a ventricular drain?
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Needs to be level with the foramen Monroe also known as midway between tragus of the ear and outer canthus of the eye
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Describe a normal and abnormal ICP wave form.
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When normal P1 is greater than P2 if abnormal P2 is greater than P1
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What are things never to be practiced with Ventricular drains?
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Never drop system down and leave it-drain out CSF, never leave open leads to infection, never attach and fluid filled drip to it, never flush only MD
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What are the nursing interventions for a patient with a ventriculostomy or drain?
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Head and neck elevated 30 degrees always, neck neutral position, avoid knee and hip flexion, always log roll, pt exhalation with turning, small doses of Ativan (false neuro status), 2-3mg (small doses) morphine (causes vasodilation and increased ICP), keep PEEP below 10, no valsalva, do not tie trach ties tightly
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