Altered LOC and Increased ICP

Question 1

Signs of altered LOC

Answer 1

decreased alertness, disorientation, confusion, slow pupillary response, changes in GCS, abnormality of cranial nerves, loss of balance/ coordination, change in reflexes, presence of pathologic reflexes

Question 2

Causes of Altered LOC

Answer 2

head injury, IC bleed, stroke, seizures, tumor, overdose, ETOH intoxication, DKA, renal failure, hepatic failure

Question 3

Signs of a coma

Answer 3

no response of verbal stimuli, no voluntary movement, varying responses to painful stimuli, abnormal posturing, altered pupin response to light, no blinking, abnormal reflexes, Cheyne Stokes respirations

Question 4

ICP or Intracranial pressure

Answer 4

hydrostatic force measured in brain tissue and CSF, normal is 0-10, 15 is upper limit, sustained 15 is dangerous

Question 5

CPP or Cerebral perfusion pressure

Answer 5

net pressure gradient that drives oxygen delivery to cerebral tissue, normal is 70-100, less than 50 leads to irreversible brain damage

Question 6

Increased ICP- cause

Answer 6

increased production of CSF

Question 7

Early symptoms of increased ICP

Answer 7

Change in LOC, Weakness, headache, vomiting, possible pupillary changes

Question 8

Late symptoms of increased ICP

Answer 8

stuporous/ comatose, reaction to painful stimuli only, abnormal posturing, cheyne stokes respirations, loss of brainstem reflexes, cushing’s triad

Question 9

Decerberate posture

Answer 9

abnormal extension

Question 10

Decorticate posture

Answer 10

abnormal flexion

Question 11

Biggest worry with increased ICP

Answer 11

Brain herniation

Question 12

Gold standard for monitoring ICP

Answer 12

Ventriculostomy

Question 13

Complications of ventriculostomy

Answer 13

Infection, meningitis, occlusion of the catheter by brain tissue or blood

Question 14

Other concerns with Increased ICP

Answer 14

Seizure, Fever, DI, SIADH

Question 15

Nursing Interventions for Increased ICP

Answer 15

Proper positioning, preventing valsalva, straining, constipation, overstimulation, controlling seizures, assessing neuro and respiratory, monitoring fluid status, I&Os, ABGs, Vitals, maintaining patent airway, oral and skin care, pain

Question 16

Major meds for increased ICP

Answer 16

dexamethasone, PPIs, antiseizure meds, Tylenol, docusate, Lovenox, heparin, mannitol, propofol, hypertonic saline, hyperoxygenation

Question 17

Nutritional therapy for increased ICP

Answer 17

Early feeding, higher caloric intake