Intracranial Pressure Flashcards
What are early signs of Increased ICP ?
- Earliest sign would be a change in LOC
- Speech may become slurred or slowed
- Delay in response to verbal suggestion (slow to respond to commands)
- Increase in drowsiness
- Restlessness with no apparent reason
- Confusion
What would the earliest sign of Increased ICP be ?
A change in LOC
–> a change may be a pronounced as going into a coma or as subtle as a change in attention span (ALWAYS assume the worst)
What are late signs and symptoms of Increased ICP ?
- Marked change in LOC progressing to stupor, then Coma
- Vital sign changes
- -> Cushing’s triad (results of pressure on the brain stem)
- Decerebrate and Decorticate Posturing
Cushing’s Trias requires immediate what? and Why ?
Immediate intervention
To prevent further brain ischemia and restore perfusion
What is Cushing’s Triad characterized by ?
- Systolic HTN, with a widening pulse pressure
- Slow, full, and bounding pulse
- Irregular respirations
(look for a change in pattern, like Cheyne stokes or ataxic respirations)
Anytime you have Decerebrate or Decorticate Posturing to painful or noxious stimuli, what does it indicate ?
Indicates that the motor response centers of the brain, the mid-brain, and the brain stem are comprimised
How does Decorticate Posturing present ?
Towards core/inward
- Arms flexed inward and bent in toward the body
- legs are extended (feet inward ?)
How does Decerebrate Posturing present ?
Presents with all 4 extremities in rigid extension; WORST
- Client will be rigid, tight, and burning more calories
Which posture, Decerebrate or Decorticate may indicate more serious damage to the brain ?
Decerebrate Posturing
What are Miscellaneous signs of Increased ICP ?
- Headaches
- Change in pupils and pupil response
- ## Projectile vomiting
Anytime you have a client with a head injury, if they start complaining of a headache, what do you assume ?
Assume that their ICP is going up
In a profound coma, what will the pupils be like ?
Fixed and Dilated
Why might Projectile vomiting occur ? and what should you assume ?
- B/c the vomiting center in the brain is being stimulated
- Assume ICP is increasing
What are complications of increased ICP ?
- Brian Herniation (pushes on the brain stem)
(the herniation obstructs the blood flow to the brain leading to anoxia and then brain death - DI and SIADH
- ADH problems are secondary to others
-
What are the Treatments for Increased ICP ?
- Maintain oxygenation
- Maintain adequate cerebral perfusion
- Keep temperature below 100.4 (38 C)
- Elevate the HOB
- Keep head midline so the jugular veins can drain
- Watch ICP monitor with turning - Monitor VS for Cushing’s Triad
- Avoid - Osmotic diuretics
- restraints - Hypertonic saline 3%
- bowel & bladder distention - Steroids
- hip flexion - FLuid restriction
- Valsalva - ICP monitoring devices
- isometrics
- No sneezing
- No nose blowing
- Limit suctioning & coughing
- Nursing interventions SHOULD be spaced
- Monitor glasgow coma scale
- Barbiturate induced coma
(if ICP can’t be controlled by other measures)
True or False:
Anytime you do something to your patient, their ICP increases ?
True
that’s why nursing interventions should be spaced
RULE:
If the Glasgow Coma scale is below is, think __________ ?
Intubate
Barbiturate Induced comas are used to do what ?
Decrease cerebral perfusion
How do osmotic diuretics work to lower increased ICP ?
Pull fluid from the brain cells and filter it out through the kidneys
Why is 3% NS (hypertonic solution) used in the Tx of increased ICP ?
Acts like an osmotic diuretic
will pull fluid from the brain to reduce cerebral edema
Why might steroids used in the Tx of increased ICP ?
To decrease cerebral edema
--> When a tumor is the cause of the increased ICP
What is a type of ICP monitoring device ?
Ventricular catheter monitor or subarachnoid screw
What is the Greatest risk of having a Ventricular catheter or subarachnoid screw (ICP monitoring device) ?
Infection
What do you want to make sure is done to decrease the risk of infection in clients with an ICP monitoring device ?
- No loose connections
- Keep dressings dry
(bacteria can move through something that is wet much easier than something that is dry)
What is the overall goal for Tx increased ICP ? How ?
- Goal is to reduce the increased ICP
- By…
- reducing cerebral edema
- reducing the amount of CSF or blood volume in the brain
Why do you Want to maintain oxygenation in clients with Increased ICP ?
B/c Decreased oxygen and increased CO2 levels cause Cerebral vasodilation, which increases ICP
What don’t you want a client with increased ICP to have in regards to Vital signs and why ?
Dont want Hypotension or Bradycardia b/c that would decrease Brain perfusion
RULE:
Increased volume = ___________ ? = _________________ ?
= Increased CO = Increased brain perfusion
Why do want to keep a clients temperature down when they have increased ICP ?
B/c an increase in temperature will increased cerebral metabolism and cerebral edema which increases ICP
________________ can be used as a treatment to decrease cerebral edema, by decreasing then metabolic demands of the brain ?
Hypothermia
______________ may also be used in to lower a clients temperature who has increased ICP ?
Antipyretics
If your turning a client with Increased ICP, and there ICP has not come back down after 15 minutes what does that mean/indicate ?
Indicates that they are not tolerating that side very well
