Intracranial regulation/increased ICP Flashcards
how long after a primary injury to the brain does a secondary injury occur?
hrs to days
what is our goal regarding secondary injuires?
prevent futher damage as these can worsen the outcome significantly beyond a primary injury
what are the three main componants that try to compensate for increased ICP?
brain tissue, blood, and CSF
what is normal ICP?. at what ICP is there a risk for ischemia and infarction?
<15. 20mmgh
how does the brain tissue compensate for increased ICP?
distention of dura, compression of tissue
how does blood compensate for increased ICP?
vasoconstriction of cerebral vessels
how does csf compensate for increased ICP?
production slows down and shifts to spinal column
what is cerebral perfusion pressure? what is its normal range? what is the necessary number for adequate perfusion? at what number is it incompatible with life?
it is the pressure needed to ensure adequate cerebral perfusion (like BP for the brain). should be 70-100. minimum is 50-60. deadly is <30.
what is the formula for CPP?
MAP - ICP
if pt’s MAP is 85 and ICP is 19, what is their CPP? is this adequate?
- it’s not ideal but its not deadly
what could hypercarbia cause in a brain injury scenario?
dilation of cerebral vessels resulting in creased ICP
if cerebral vessels were vasoconstricted and CPP was decreased, what could this be a resut of?
hypocarbia
what three things are very important for nurse to monitor and keep withint normal range after a brain injury?
BP, O2 levels and CO2 levels (requires ABG)
which things should a nurse keep in mind related to positioning when managing a patients ICP?
HOB at 30 degrees and avoid sudden changes (like abrupt standing).
keep head midline and avoid neck flexion.
avoid hip flexion
avoid coughing and straining
which of these interventions is incorrect in managing a delicate ICP patient?
- give laxatives to prevent constipation
- give oxygen before and after suctining
- cluster care to give patient long rest periods
- maintain quiet environment and limit visitors
clustering care is incorrect. We want to give patient breaks between nsg care. they can’t handle a lot of interventions at once without having increased ICP
when compensatory mechanisms are in tact, what are the signs of increased ICP we will see?
- unilateral pupil change in size, reactivity
- altered resp pattern (brady or irreg)
- unilateral hemiparesis
- speech and visual disturbances
- papilledema
- vomiting
-headache
-seizures
a patient with head injury is vomiting, complaining of greying out of their vision, and one of the pupils is larger and less reactive than the other. are these early, late , or terminal signs of increased ICP?
early
True or false: Cheyne-Stokes respirations are a terminal sign of increased ICP
false, these are LATE signs when the compensatory mechanisms are failing
patient has hypertension with widened pulse pressure, and bradycardia. what is this considered?
cushings triad
when a patient has decompensated with increased ICP, what is their LOC and what are their respirations like?
Coma, resp arrest
what are early indicators of altered LOC?
restlessness, irritability
if someone’s GCS is less than 8 and we need to monitor ICP closely and possibly drain CSF, what procedure would be done? What unit would this occur on?
external ventricular drain (EVD). ICU or stepdown
three nursing considerations for EVD
high risk of infection (proph abx),
body position should not change
- transducer stays level with foramen of monro (tragus of ear)
why would we give Lasix for IICP?
adjunctive to mannitol
why would we give corticosteroids for IICP?
decrease inflammation from brain tumor
what two reasons would we give NS 3% in head injury?
to reduce ICP, and to treat low sodium which is common in IICP
is it indicated or contraindicated to insert an NG tube for IICP?
can be indicated to relieve pressure on diaphragm in order to increase respiratory impact. (However, if there might be a skull fracture it would not put on in)
why would we monitor urinary output with IICP?
because brain tumor or injury can cause DI and SIADH
why do we want to control fever and pain with IICP?
because higher temp means high metabolism which increases ICP
what improves outcomes after brain injury?
early feedings
IICP is a(n) ________ ________ and _______ state
increased hypermetabolic and catabolic
why would someone with IICP be at risk for injury? how can we protect them?
because they have risk for seizures and and confusion/agitation. we can pad the side rails and possibly light sedation.
