Increased intracranial pressure Flashcards
patho, complications, risk factors, signs and symptoms, treatment, managements and post care
what does increased intracranial pressure mean?
high amounts of pressure in the head; which can lead to squishing the brainstem and lead to breathing issues and heart rate
what are some causes of increased intracranial pressure?
stroke
inflammation- head trauma
tumor
can you explain and walk through the patho behind increase icp?
with the amount of pressure in the brain increasing, it can place pressure on the vessels and arteries that carry out oxygen to the rest of the body.
This compression and lack of oxygen ends up leaving our patient with a reduced level of consciousness or decreased mental status - hypoxia
what is the earliest/ first sign of increased intracranial pressure?
altered level of consciousness
decreased mental status
what are some other early signs that a patient with increased icp may have?
altered LOC ; irritability, restlessness
decreased mental status
sleepiness
flat affect and drowsiness
what are moderate signs and symptoms (2)?
headache - constant
sudden vomitting without nausea
what is a way the body helps regulate and maintain icp?
monro-kellie doctrine
what is the monro-kellie doctrine?
in essense
increased CSF
decrease blood and brain tissue
what is normal icp ?
5-15
what is the range of pressure that is needed to maintain blood flow to the brain?
60-100
what are the 4 stages of increased icp?
stage 1. compenstation
stage 2. decreaed comp
stage 3. cushing triad
stage 4. herniation and death
late and deadly signs include what?
lungs -
neck -
eyes -
foot -
irregular respirations
( cheyne-stokes respirations )
nuchal rigidity
( stiff neck )
pupils are fixed and dilated or unequal
babinksi relfex is positive
typically on a test, when a patient complains about not being able to flex chin towards the chest, we want to think about what?
a late, deadly sign of increased intracranial pressure
what is normal dilation of the pupil?
2-6
what type of eye movement do we want or looking for when we are turning the patient ?
dolls eyes
- their eye move in the opposite direction when the head is turned
when do we see seizures and comas typically for patients in increased icp?
early, moderate or late signs?
late signs
when do we see abnormal posturing in patients with increased icp?
early, moderate or late sign
late
what are the two postures and briefly describe them ?
decortibate - flex to core
decerebreate - extension out of core
we talked about cushing triad in another flashcard group, can you tell me the 4 signs and symptoms that happen in late increased icp?
widening pulse pressure
hypertension
bradycarida
decreased respirations
what are diagnostic studies we do for patients with increased icp?
CT scan
why do we not do a spinal tap or lumbar puncture for a patients with icp?
can cause herniation
client found on the floor, appearing lethargic, bleeding at the back of the head, heart rate of 45 bpm, and a blood pressure of 220/88. What is the first action?
immediately c-spine immbolization & ct-scan to rule out intracranial bleeding
what is the anagram that we can use for a patient with increased icp to help remember the nursing interventions?
ICPS
what does icps stand for ?
immbolize head ( c-spine )
- head in neutral position
- log roll as one unit
Co2 LOW - aids with vasodilation
( normal is 35-45)
- hyperventilate to blow off co2
positiong
semi-fowlers (30-35)
NO FLEX OR BENDING
no coughing, sneezing, blowing nose, valsalva manevuers
suctioning
10 seconds or less
limit it
100% oxygen before and after
what type of movement are we going to do for a patient with an immbolize head in a c-spine ?
log roll them
- as if they were one unit
why do we want carbon to be low for a patient with increased icp?
because lowering carbon can help aid with vasodilation and promote reducation of pressure - this is why we hyperventilate if they are on a machine to push out all the carbon
what type of position do we want patients with icp to be in?
what is the head of the bed at?
semi-folwers
30-35
what are we instructing the patient to not do? (6)
these things increase the pressure in the brain
cough, sneeze, blowing, flexing, bending, valsva manuvers
if the patient wants to move, what do we instruct them to do in order to help avoid pressure in the head?
exhale when turning or moving in bed
immediate intervention when client with icp states
- i will turn cough and deep breathe
why is this super bad!!
because it creates so much pressure
how long are we going to be suctioning for?
should we do this often?
10 seconds or less
no, limit it as much as possible
before and after we suction a patient with increased intracranial pressure, what are we going to do?
hyperoxygenated 100% oxygen
what type of scale are we going to use to measure level of consciousnes?
GCS
what is the range of gcs?
lower than ___we intubate
whats the lowest ?
3-15
8
3
client recovering from a head trauma, gcs of 14 over 2 ohurs ago but now reporting a gcs score of 11, what do we do ?
report to the hcp immediately
if a patient doesnt have a gag reflex, should we intubate them?
yes
inaccurate readings can be caused by csf leaks, obstruction, differences in height of bolt, bubbles or air in the tubing,
so we should always base our assessment on what rather than what?
assess patient first before machine
increased intracranial pressure is a what and not a what?
symptom
not a condition
we can control icp by removing csf with what?
ventricular catheter with intermittent or continous drainage
why is infection at its highest here with a ventricular catheter?
direct entry way to the brain
- highest risk if its still in placed for more than 5 days
drug therapy now regarding increased icp
what are we going to use to help pull out the fluid from the head (2)?
what are we goint to use to help with the swelling and inflammation in the head? (2)
what are we going to use to prevent seziures?
mannitol or hypertonic saline
corticosteroids and barbitues
phenytoin
if we are going to manage the pain for patients with icp with opioids, what shuold we take into consideration?
sedation
- causes drowsy and can distrub neuro exams
what is the best pain medication we like giving to patietns with icp and why?
propofol (diprivan)
- short half life, so easy to do neuro exams
what is the amount of fluid these patients can consume?
1200 per day
why would the patient shivering be a bad sign and should be corrected for a patient with icp?
shivering can increase the pressure
why would we want to give antipyrteics?
helps avoid a fever
why would we give msucle relaxnats?
it would help prevent shivering
