Increased ICP

Question 1

Risk Factors

Answer 1

1) Head trauma
2) Infection
3) Intracranial tumor

Question 2

Physical assessment

Answer 2

1) Lethargy
2) Decreased LOC
3) Slowing of speech
4) Papilledema
5) Headache

Question 3

Complications

Answer 3

1) Hydrocephalus
2) Diabetes insipidus
3) Death

Question 4

Priority Nursing Diagnosis

Answer 4

Altered Self-care ability r/t confusion and grogginess AEB falls asleep during attempts at bath

Question 5

Patient outcomes

Answer 5

1) Pt will resume self-care by discharge
2) Pt will have adequate assistance with hygiene and dressing

Question 6

Diagnostic Confirmation or Findings

Answer 6

1) CT scan
2) Glasgow Coma Scale
3) Vitals
4) Eye exam

Question 7

Treatment

Answer 7

1) Warm blankets
2) Monitor electrolytes
3) Keep HOB elevated at 20 to 30 degrees
4) Keep head and neck midline
5) Hip flexion should be less than 90 degrees

Question 8

Medication Used

Answer 8

1) Furosemide
2) Dexamethasone
3) Barbiturates

Question 9

Pathophysiology

Answer 9

Any lesion or fluid taking up space in the cranial cavity