Final: Increased Cranial Pressure

Normal ICP

0-15 mmHg

lowest glasgow coma score

3 (dead)

CPP range

70-100 normal 150 = vessels cannot constrict more less than 50 = ischemia and necrotic (blurred vision and syncope) less than 30 = not compatible with life

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Loss of consciousness

The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report?

The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6.

ICP Definition

The pressure exerted by the total volume from the brain tissue, cerebral blood, and cerebral spinal fluid

Which method is used to help reduce intracranial pressure?

Using a cervical collar

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure

factors that increase ICP

arterial pressure venous pressure intra-abdominal and thoracic pressure (straining, exercise, cough) posture (higher in supine than standing) temperature blood gases/CO2 levels

ICP remains relatively constant due to

autoregulation

cerebral blood flow

brain has ability to regulate its own blood flow in response to metabolic needs brain uses 20% of bodies oxygen and 25% of bodies glucose

vasogenic cerebral edema

break down of blood-brain barrier causing fluid to penetrate into parenchymal extracellular space WHITE MATTER

factors effecting CBF

carbon dioxide: increase co2 relaxes smooth muscles causing vasodilation resulting in increased CBF oxygen: low oxygen and high hydrogen ions causes vasodilation (acidosis)

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

decerebrate

motor symptoms

decerebrate posturing (extensor) decorticate posturing

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

decorticate

best practice for measuring ICP

in ventricles

ICP nursing care

1. infection 2. drain CSF prn 3. nutrition needs (increase need for glucose) 4. iV 0.9NaCL

Nursing care

1. neuro checks q 1-2 hours 2. fluid and electrolyte balances 3. ICP 4. maintain airways always!! 5. HOB @ 30 6. skin integrity 7. monitor for constipation, bladder distention and prevent pt from coughing 8. quiet environment w low stimuli 9. hyperventilation therapy (watch for ischemia)

highest glasgow coma scorer

15

causes of cerebral edema

mass lesions ie tumor (cytotoxic edema) head injury (vasogenic) brain surgery cerebral infection ie meningitis or encephalitits vascular insident (stroke) toxic/metabolic encephalopathic condition

if pt has glasgow coma score of 8 7?

measure ICP 7 = coma

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

monro-kellie

cushings triad

hypertension bradycardia irregular respirations (bradyepnea)

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

maintenance of airway

interstitial cerebral edema

periventricular diffusion of ventricular cerebral spinal fluid in a patient with uncontrolled hydrocephalus or caused by water intoxification

cerebral perfusion pressure

pressure needed to ensure blood flow to brain CPP = MAP-ICP

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

severe TBI

pressure volume curve stages

stage 1: high compliance stage 2: decrease compliance resulting in risk for increased ICP stage 3: any small addition in volume causes a big change in ICP - loss of autoregulation stage 4: ICP rise to lethal levels

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness

signs and symptoms of cerebral edema

first: blurred vision HA projectile vomiting later: change in LOC - suspect ICP of any pt who suddenly becomes unconscious change in vitals (cushings triad) fixed dilated pupils

modified monro-kellie doctrine

if the volume in any one of the categories increase the volume from another will decrease (homeostasis)

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

increased ICP

lack of glucose for 5 minutes results in

irreversible brain damage

cytotoxic cerebral edema

local disruption of cell membrane integrity (BBB intact) GRAY MATTER

types of cerebral edema

vasogenic cytotoxic interstitial