Increased Intracranial Pressure

Question 1

What is the normal intracranial pressure range?

Answer 1

5-15mm Hg

Question 2

What are the common causes of ICP?

Answer 2

Trauma, hemorrhage, edema tumors

Question 3

What do you assess? ____ ____ ____

Answer 3

Level of conscious

It decreases as ICP increases.

Question 4

This is the earliest sign of ICP

Answer 4

Decreased level of consciousness

Question 5

The client will often appear?

Answer 5

Restless, agitated, complaining of head aches

Question 6

What will babies physically present with?

Answer 6

Bulging fontanelles

Question 7

Late signs of ICP are?

Answer 7

Unilateral pupil dilation, hypotention, bradycardia

Question 8

Client may complain of ____ ____ ___ ____

Answer 8

Projectile vomiting without nausea

Question 9

How will the vital signs appear with ICP?`

Answer 9

B/P (up), Temp (up), Resp (up then down), Heart rate (up)

Question 10

What is widening pulse pressure and how is it related?

Answer 10

When systolic blood pressure goes up and diastolic continues to go down so that they become further apart (e.g., 135/40 is a bad sign!)

Question 11

What is Cushing’s Triad?

Answer 11

Three things; widening pulse pressure, Cheyne stokes respirations, and bradycardia

Question 12

Initiate____ precautions

Answer 12

Seizure

Question 13

Elevate head of bed to?

Answer 13

10 to 30 degress, to promote jugular venous outflow

Question 14

What medications will be prescribed?

Answer 14

Anticonvulsants
Blood pressure medications
Corticosteroids
Diuretics

Question 15

Tell the client not to ____ _____ ____ or ____

Answer 15

Strain, cough, or sneeze

Question 16

Nursing interventions would be to?

Answer 16

Decrease environmental
stimuli. Maintain body temperature. Limit fluid intake.
Monitor intake and output