Increased ICP General Care Flashcards
Normal ICP?
0-15 mmHg
Early signs of increased ICP
Earliest sign?
Change in LOC
Early signs of increased ICP
Speech
Slurred or slowed
Early signs of increased ICP
Delay in response to ____ suggestion
Verbal
*slow to respond to commands
Early signs of increased ICP
Increase ___
Drowsiness
Early signs of increased ICP
___ with no apparent reason
Restless
Early signs of increased ICP
Confused?
Yes
Late signs of increased ICP
Marked change in LOC progressing to ___ then ___
Stupor then coma
Late signs of increased ICP
VS changes?
Cushing triad!!! –Immediate intervention to prevent brain ischemia
Late signs of increased ICP
What is cushing triad?
Systolic HTN with widening pulse pressure
Slow, full, bounding pulse
Irregular respirations
Narrow pulse pressure = ?
Cardiac tamponade
Wide pulse pressure= ?
Late sign of increased ICP
Late signs of increased ICP
What respiration pattern?
Cheyne stokes or ataxic respirations
Late signs of increased ICP
Posturing
A response to painful or noxious stimuli
*posturing indicates that the motor response centers of the brain are compromised
Late signs of increased ICP
What is decorticate posturing?
Arms flexed inward and bent toward the body and legs are extended
Arms flexed
Legs extended
Late signs of increased ICP
What is decerebrate posturing?
All 4 extremities in rigid extension
Late signs of increased ICP
What is worse: decorticate or decerebrate?
Decerebrate
Misc. signs?
HA
Changes in pupils and pupil response
Projectile vomiting
Misc. signs
Pupils in profound coma?
Fixed and dilated
Misc. signs
Why projectile vomiting?
Vomiting center in brain is being stimulated
Complications of increased ICP?
Brain herniation
DI and SIADH
Treatment of increased ICP
Maintain ___
Oxygenation –most controlled with vent
*decreased O2 and high CO2 cause cerebral vasodilation which increases ICP
Treatment of increased ICP
Maintain adequate cerebral perfusion. How?
Don’t want hypotension or bradycardia bc that would decrease brain perfusion
Give isotonic saline and inotropic agents (dobutamine and norepinephrine)
Treatment of increased ICP
Keep temp at?
Below 100.4 F
- increased temp = increase cerebral metabolism = increase ICP
- hypothalamus may not work and you would need to get a cooling blanket
- hypotheremia is used as a tx to decrease cerebral edema by decreasing the metabolic demands of brian
Treatment of increased ICP
HOB
Elevate
Keep head midline so jugular veins can drain
*watch ICP monitor when turning client
Treatment of increased ICP
Avoid
Restraints Bowel/bladder distention Hip flexion Valsalva Isometrics No sneezing No nose blowing Limit suctioning and coughing
Treatment of increased ICP
Nursing interventions
Space them –anytime you do something with client, it increased ICP
Treatment of increased ICP
Monitor GCS…explain
GCS below 8, intubate
Treatment of increased ICP
VS
Monitor for cushing
Treatment of increased ICP
What does barbiturate induced coma do?
Decreases cerebral metabolism
Treatment of increased ICP
What does osmotic diuretics do?
Pull fluid from brain cells and filters out through kidneys
*osmotic diuretics can crystallize
Treatment of increased ICP
What do steroids like dexamethasone do?
Decrease cerebral edema
Treatment of increased ICP
ICP monitoring device
Greatest risk?
No loose ____
Keep dressings moist or dry?
Ventricular catheter monitor or subarachnoid screw
Infection
No loose connections
Keep dressings DRY (bacteria can travel through something that is wet much easier than something that is dry)
