NEURO: INTRACRANIAL PRESSURE (ICP)

Question 1

Pt with ventro-peritoneal shunt increase ICP s/s?

Answer 1

Early s/s:  
***Altered LOC is the most sensitive and earliest indication of increasing ICP***
H/A
Abnormal respiration
N/V
Blurred vision
Pupil changes

Late s/s:  
decrease LOC
POSITIVE BABINSKI REFLEX
alteration in pupil size and reactivity
decorticate or decebrate posturing
bradycardua
widening pulse pressure
Children may display sleep disturbance

Question 2

ICP and CO2

Answer 2

CO2 potent vasodilating effect increase cerebral blood flow and ICP
TX: Hyperventilate to decrease CO2 levels

Question 3

ICP and suctioning

Answer 3

Suctioning cause coughing leads to hypoxia and valsalva maneuver and elevated ICP

Question 4

ICP and oxygen concentration

Answer 4

Oxygen concentration may initially decrease ICP bu too much can lead to pulmonary fibrosis and seizures

Question 5

Pt with head trauma and increasing ICP name 3 nursing interventions

LIMIT SUCTIONING B/C IT INCREASES ICP

Answer 5

1) ELEVATE THE HEAD OF BED ( promotes venous flow)
2) PROVIDE QUIET ENVIRONMENT
3) TURN OFF UNNECESSARY LIGHTS

Question 6

ICU pt with head trauma on continuous mechanical vent develops ICP
What will DECREASING VENT SUPPORT WILL CAUSE?

Answer 6

Decreasing vent support will cause the pt to worker harder and increase ICP to dangerous levels

Question 7

Pt head injury MVA increasing ICP, nurse interventions to decrease ICP

1) Medication
2) HOB and neck alignment
3) Space out activities

Answer 7

1) Mannitol
2) Elevate HOB, maintain neutral neck alignment
3) Yes space out activities

Question 8

Pt head injury MVA increasing ICP, nurse interventions to decrease ICP
1) Assess pupil reactivity?

Answer 8

1) This is an assessment but will not decrease ICP

Question 9

ICP inside cranium consists of three substances?

Answer 9

CSF
Blood
Tissue

Question 10

NORMAL ICP values

Answer 10

Range 0-10mmHg sometimes 15mmHg

NCLEX Mastery

Question 11

Typically first sign of increased ICP?

Answer 11

Change in LOC

Question 12

Increased ICP levels cause pressure on the brainstem affecting pt’s motor fxn showing signs of posturing (2)

Answer 12

Decorticate or Decerebrate

Question 13

Increased ICP
Cushing’s triad: ? Late signs that represent a loss of compensatory mechanisms and is a presentation of ___?_ dysfunction

Answer 13

1)  Cushing Triad:
Increase BP
Decrease pulse
Altered respiration
2)  Brainstem dysfunction

Question 14

Decrease BP
Increase Pulse
Increase Respirations
are symptoms of___?___

Answer 14

Shock

s/s
Shock, which may cause any of the following symptoms:
Confusion or decreasing alertness
Clammy skin
Dizziness or light-headedness after an injury
Low blood pressure
Paleness (pallor)
Rapid pulse, increased heart rate
Shortness of breath
Weakness

(MedlinePlus)

Question 15

Increased ICP are opposite of shock symptoms? T or F

Answer 15

T

Question 16

Symptoms of Internal Bleeding

MedlinePlus

Answer 16

Symptoms of internal bleeding may also include:

Abdominal pain and swelling
Chest pain
H/A dizziness
External bleeding through a natural opening
Blood in the stool (appears black, maroon, or bright red)
Blood in the urine (appears red, pink, or tea-colored)
Blood in the vomit (looks bright red, or brown like coffee-grounds)
Vaginal bleeding (heavier than usual or after menopause)
Skin color changes that occur several days after an injury (skin may black, blue, purple, yellowish green)

Question 17

Decorticate Posturing

Answer 17

Client flexes one or both arms on the chest and may extend the legs stiffly

Question 18

Decorticate Posturing indicates nonfunctioning ___(part of brain)

Answer 18

Nonfunctioning cortex

Question 19

Decerebrate Posturing

Answer 19

Client stiffly extends one or both arms and possibly the

legs.

Question 20

Decerebrate Posturing indicates nonfunctioning ___?___ (part of brain)

Answer 20

Nonfunctioning brainstem