HEAD INJURY Flashcards
1
Q
what are clinical manifestations of an increased ICP in infants?
A
- bulging fontanels
- irritability
- high pitched cry
- setting sun sign
2
Q
what is the setting sun sign?
A
eyes downward and can see sclera above
3
Q
what are clinical manifestations of an increased ICP in children?
A
- headache
- forceful vomiting
- blurred vision
- seizures
4
Q
what are late clinical manifestations of increased ICP?
A
decreased LOC, cushing’s triad, abnormal posture (decerebrate and decorticate)
5
Q
what are priority nursing assessments to follow with a patient who has an increased ICP?
A
- AIRWAY first
- spine is stabilized, monitor LOC, ICP, O2saturation
- decrease ICP
6
Q
how can the nurse help decrease an increased ICP?
A
- keep HOB at 30 degrees
- avoid flexion and extension
- minimize oral suction and nasal suctioning is contraindicated
- avoid coughing and blowing nose
- calm environment and seizure precautions
7
Q
what is a VP shunt?
A
a VP shunt drains excess CSF into the abdomen which helps decrease ICP
8
Q
why would a VP shunt be performed on a patient?
A
- treats hydrocephaly
- obstruction of CSF flow
- impaired reabsorption of CSF
9
Q
what complication can occur from a VP shunt and what signs will a patient have?
A
VP shunt can cause shunt infection which can cause:
- changes in LOC
- fever
- signs of increased ICP
- sleep disturbances
- no appetite
