Increased Intracranial Pressure Flashcards
what is normal ICP?
normal ICP should be between 5-15 mm Hg, above 15 means there is a lot of pressure in the brain
what is normal CPP?
cerebral perfusion pressure normals range from 70-95
How can you can calculate CPP?
MAP-ICP = CCP
what is the first sign of an increased ICP?
Decreased LOC is always the first sign
what is the cushing’s triad and when does it occur?
cushing’s triad is very bad and is a late sign of IICP.
- hypertension with widening pulse pressure
- bradycardia
- irregular respirations (cheyne-stokes)
what are clinical manifestations of an increased ICP?
- decreased LOC
- severe headache
- pupils will be uneven, sluggish and blurry
- increased fever
- decorticate or decerebrate posturing
- cushing’s triad
How should the nurse assess a patient’s ABGs if they have increased ICP?
keep CO2 at a low normal (35-45) because CO2 dilates cerebral vessels and increases cerebral blood flow so constriction is necessary
how can the nurse help keep CO2 low in a patient experiencing IICP?
intubate and then increase respirations to decrease CO2
what does the nurse want the PaO2 of a IICP patient to be?
keep PaO2 > 60
what interventions can the nurse do to decrease ICP for a patient?
- keep HOB at 30 degress but no higher
- maintain body midline and c-spine until cleared
- provide a calm environment
what diagnostic test cannot be given for a patient with increased ICP?
lumbar puncture due to the risk of herniation
what is a ventricuostsomy?
a sterile procedure that measures ICP and can also help treat increased ICP because it releases CSF through sterile drainage system and releases pressure
where should the transducer be placed during a ventriculostomy procedure?
keep the transducer “0” at the level of tragus
how frequently should neuro checks be done with a patient who has IICP?
neuro checks (GCS) should be done typically every 15 minutes for at least 24 hours
what ranges should a patients blood glucose be at if they have an increased ICP?
keep blood glucose at 140-180 because these patients need alot of energy and if their glucose thanks (hypoglycemia), it can be DEADLY