adult health

Question 1

Increased ICP:

Answer 1

The earliest and most
sensitive sign of increasing ICP is a decreased LOC.

Question 2

Positioning:

Answer 2

Position a client with increased ICP with the HOB 30 degrees and head midline. Avoid
Trendelenberg position and hip or neck flexion.

Question 3

Avoid ICP spikes:

Answer 3

Teach the client with increased ICP to avoid straining and coughing. Limit suctioning
and avoid performing multiple procedures simultaneously. Decrease environmental stimuli
(minimize noise, dim lights, limit visitors).

Question 4

Cushing triad:

Answer 4

Cushing triad is a life-threatening late sign of increased ICP. It is characterized
by widening pulse pressure, bradycardia, and
irregular respirations.

Question 5

CSF leak:

Answer 5

Test any drainage from the ears or nose for the presence of glucose. A halo sign around
blood on a dressing indicates CSF (a yellow ring of
CSF forms around the blood).