Neurlogical (ICP, Stroke, GBS, Bacterial Meningitis) Flashcards
Pathophysiology of ICP
Increased pressure within the head compresses blood vessels leading to cerebral hypoxia & can put pressure on the brain stem - killing the patient
Causes of ICP
Aneurysm stroke: burst blood vessels that fill up the brain with blood.
• Head Trauma or Meningitis: Increased swelling & inflammation.
• Tumor: Increased brain tissue
more inflation for patient with ICP = ?
more pressure in PTs with ICP
Early SIgns /Symptoms of ICP
Reduce/Altered LOC: Irritability, Restless
Decreased Mental Status, Sleepiness
Flat affect and drowsiness
Report to HCP
Moderate signs of ICP
Headache - Constant Sudden Vomiting “Emesis” Without Nausea = Report to HCP!
Critical Late signs of ICP
Cushing triad Wide pulse pressure • HIGH BP “Hypertension” • Low HR “Bradycardia” Low RR “Decreased Respirations”
Late DEADLY Signs of ICP
Lungs: • Irregular Respirations
•“Cheyne Stokes Respirations”
Neck: • Nuchal rigidity (stiff neck)
• “Can not FLEX chin toward chest”
Brain Stem Affected:
Eyes • Pupils “Fixed & Dilated”
• Unequal
• 8 mm (Normal 2 - 6 mm)
• Doll’s eyes: this means Brainstem is intact if eyes move opposite of where head is Turing
• If the eyes stay fixed & dilated when the head is turned, it means BRAINSTEM is affected.
Foot • Babinski reflex (Toes fan out when stimulated = BAD) means brain stem herniation! Normal in an infant less than 2yrs old, NOT NORMAL in adult!
Seizures & Coma
Abnormal posturing: • Decorticate: arms flex toward core
• Decerebrate: arms flexed out to sides = Far WORSE!
if a patient has suspected intracranial hypertension, What can be done
a monitoring device may be placed within the cranium to quantify ICP in serial cases. The device is used to monitor serial ICPs and assist with the management of intracranial hypertension. and assist with the management of intracranial hypertension. An increase in ICP can decrease blood flow to the brain, causing brain damage. The monitoring device can also provide a sterile access for draining excess CSF. The four sites for monitoring ICP are the intraventricular space, the subarachnoid space, the epidural space, and the parenchyma. Each site has advantages and disadvantages for monitoring ICP.
Priority assessment findings for a client recovering from a head trauma? Select all that apply
- Eyes that move in the opposite direction when patient is turned.
- Extremities that contracted to the core of the body.
- Fixed pupils that remain 8mm when assessed with a pen light.
- Level of consciousness that has not diminished since admission.
- Grips 5/5 bilateral Toes that fan out when the sole of the foot is stroked.
- Toes that fan out when the sole of the foot is stroked.
correct answer : 2.Extremities that contracted to the core of the body.
- Fixed pupils that remain 8mm when assessed with a pen light.
- Toes that fan out when the sole of the foot is stroked.
Diagnostic imaging for ICP
• Imaging - CT scan
• 1st test - quick easy picture of the brain
- showing the root cause
• NOT an MRI - they are too long & slow
• NO lumbar puncture (spinal tap)
• ICP monitoring (for long-term patients)
-Normal ICP: 5 - 15 mmHg
-HIGH RISK of infection!
*brain drain is accurate but risk of infection is high ( only used in serious long term patients, ex: Coma)
what is the number one test hat is quick and easy to use on ICP patient
CT scan
Client found on the floor, appearing lethargic, bleeding at the back of head, heart rate of 45 BPM & a blood pressure of BP 220/88. First action?
Immediate C- Spine immobilization & CT scan to rule out intracranial bleed
Normal ICP
5-15 mmHg
True or false :
most current evidence suggests that ICP generally must be treated when it exceeds 20 mm Hg.
True
Nursing Intervention for ICP
I: Immobilize Head “C-Spine”: • Head in neutral position
• Log Roll “As one unit”
C: C02 LOW : Lower CO2 means Lower ICP. Carbon dioxide vasodilates the brain resulting in more swelling from more blood flow. Hyperventilation decreases CO2 by blowing it out
P: Positioning : HOB - Semi-Fowler’s 30 - 35 Degrees or higher
NO valsalva maneuvers or holding breath
NO coughing, sneezing, blowing nose
NO flexion & bending extremities
S:Suctioning:10 Seconds or Less 100% O₂ before/after suction
*perform neuro checks too
True or False : The rationale employed in hyperventilation is that if PaCO 2 can be reduced from its normal level of 35 to 40 mm Hg to a range of 25 to 30 mm Hg in a patient with intracranial hypertension, vasoconstriction of cerebral arteries, reduction of CBF, and increased venous return will result. This practice is being reexamined.
True
true or false:
The current trend is to maintain PaCO 2 levels on the lower side of normal (35 mm Hg ± 2) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings.
True
Client on ventilator… increased PaCO2. The nurse receives an order to increase the respiratory rate on the ventilator. This change should have what change on the patient’s ICP?
Decrease the ICP …. decrease in carbon dioxide.
Patients with ICP should turn cough and deep breathe…..
true or false
False
interventions.. increased ICP & ineffective breathing pattern? Select all that apply
Suction no longer than 10 seconds
100% O₂ before and after suctioning
Perform neuro checks using GCS
Interventions for increased ICP? Select all that apply
Position - Semi-Fowler’s Suction only as necessary but no longer than 10 seconds Position avoid flexion of hips, waist, and neck
Teach avoid Valsalva maneuver
Place neck in neutral position
What happens if doing care/activities to patient with ICP constantly
increases ICP
True or false :
Family contact and gentle touch associate in increases in ICP
False, it actually can decrease ICP
