Increased ICP Flashcards
Where are the common causes of ICP?
Trauma, tumors, hemorrhage, edema,
What do you assess
Levels of consciousness (it decreases as ICP increases)
What is the earliest sign of ICP
____ level of consciousnes
The client will often appear ___, ____, and complaining of _____
Decrease level of consciousnes
The client will often appear restless, agitated, and complaining of headaches
What sign will appear in babies?
Bulging fontanelle
Late signs of ICP
Hypotension
Bradycardia
Unilateral pupil dilation
The client may complain of
Projectile vomiting without nausea
How will vital signs appear with ICP?
BP up,
Heart rate up
Temp up,
respiration up then down
What is Widening pulse pressure and how is it related?
Win systolic blood pressure goes up and diastolic continues to go down so they become further apart!!
A bad sign
What is Cushing’s Triad?
Three things
- Bradycardia
- widening pulse pressure
- cheyne strokes respiration
Initiate_____precautions?
Seizure
You elevate the head of bed to?
10 to 30°, to promote jugular Venous outflow
What is the normal intracranial pressure range?
5 to 15 mm Hg
What medications will be prescribed?
diuretics
Blood pressure medication
Anticonvulsants
Corticosteroids
To the client to avoid?
sneezing,Straining or coughing
4 Nurse interventions
____ environmental stimuli
____ body temperature
____ intake and output
___ fluid intake
Decrease environmental stimuli
Maintain body temperature
Monitor intake and output
Limit fluid intake
