Chapter 56 ICP neuro
A patient has increased intracranial pressure (ICP). The nurse evaluates the patient's level of consciousness and records a Glasgow Coma Scale (GCS) score that indicates the patient is in a comatose state. What would be an appropriate GCS score? Select all that apply.
-4 -5 -6 A GCS score of 8 or less (4, 5, and 6) generally indicates coma. Scores of 9 or 11 are greater than 8 and do not indicate coma.
The nurse is caring for a patient with increased intracranial pressure (ICP). What actions should the nurse perform as a part of nutritional therapy? Select all that apply.
-Begin parenteral nutrition if oral intake is not adequate -Begin nutritional replacement within three days after injury -Evaluate the patient's urine output, fluid loss, and electrolyte balance For a patient with increased ICP, parenteral nutrition should be started if oral intake is not adequate. Nutritional replacement should begin within three days after injury. The patient's urine output, fluid loss, and electrolyte balance should be monitored to evaluate the effectiveness of nutritional therapy. The patient should not be kept in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, full nutritional replacement should be reached within seven days after injury.
A patient with elevated intracranial pressure (ICP) is at risk for lower cerebral perfusion pressure (CPP) during suctioning. The nurse should maintain CPP above how many mm Hg to preserve cerebral perfusion?
60 Patients with elevated ICP are at risk for lower CPP during suctioning. CPP must be maintained above 60 mm Hg to preserve cerebral perfusion.
A patient is admitted to the emergency department with a closed head injury. The patient is awake but lethargic, and the baseline vital signs include a blood pressure of 120/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute. Two hours later the nurse assesses the patient. Which finding indicates deterioration in the patient's condition?
Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute. Late signs of increased intracranial pressure include an increased systolic blood pressure and decreasing diastolic blood pressure (widening pulse pressure), bradycardia, and decreased respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing's triad and require immediate intervention. Not remembering what happened, a sleeping patient who awakens in response to painful stimuli, and a blood pressure of 110/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute do not necessarily indicate deterioration in the patient's condition.
A patient with a brain injury is experiencing a change in motor function. Which motor function response is depicted in the image?
Decorticate posturing Decorticate posture involves internal rotation and adduction of the arms with extension of the elbows, wrists, and fingers, as illustrated in the image. This results from interruption of voluntary motor tracts in the cerebral cortex. Extension of the legs may also be seen. A decerebrate posture may indicate more serious damage and results from disruption of motor fibers in the midbrain and brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar extension of the feet. Sinusoidal posturing does not exist. Opisthotonic posturing consists of the head, neck, and spinal column in an arching position.
A patient has a systemic blood pressure of 120/60 and an intracranial pressure (ICP) of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results?
Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = systolic blood pressure (SBP) + 2 (diastolic blood pressure [DBP])/3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP-ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.
A patient was ejected from a car during a motor vehicle crash and has a diagnosis of subdural hematoma. Which type of brain injury does this represent?
Primary Primary injuries are those that occur at the time of the injury (blunt force trauma, car accident); the subdural hematoma is itself an example of this. Secondary injuries are those injuries resulting from the primary injury; for instance, increased intracranial pressure may result from the hematoma. A cerebral injury is damage to the cerebrum, and an anoxia injury results from a lack of oxygen to the brain.
The nurse administers mannitol that has been prescribed for a patient with increased intracranial pressure. What outcome does the nurse expect after administration?
Reduced intracranial pressure Mannitol (Osmitrol) is an osmotic diuretic that increases osmotic pressure in the renal tubules. This increases uptake of water and diuresis, which specifically helps relieve cerebral edema, thereby decreasing intracranial pressure. Increased urine output, decreased blood pressure, and increased intracranial perfusion are secondary outcomes of administration of mannitol (Osmitrol). Of these, increased intracranial perfusion is most desirable because it reduces intracranial pressure. Blood pressure must be monitored closely because an extreme decrease in blood pressure may occur, resulting in decreased intracranial perfusion.
The nurse is positioning a patient who has increased intracranial pressure (ICP). Which is the most appropriate position for this patient?
Semi-Fowler's A patient with increased ICP should be positioned with his or her head elevated, as in semi-Fowler's position. Sims' position is side-lying with one leg flexed which may elevate intracranial pressure, prone is flat with the face down, and Trendelenburg is supine with the feet higher than the head. The head is not elevated in these positions, which is dangerous for someone with ICP.
A nurse is using the Glasgow Coma Scale (GCS) to assess a patient who fell out of a tree and sustained a head injury and developed increased intracranial pressure. Which components will the nurse assess?
Speaking, responding to stimuli, and following verbal commands The GSC assesses a patient's ability to respond to stimuli, speak, and follow verbal commands. Swallowing and pupillary response are not components of the GSC.
A nurse is caring for a patient with a closed head injury and increasing intracranial pressure. Which of the following manifestations does the nurse report to the health care provider that represent Cushing's triad? Select all that apply.
-Bradycardia -Irregular respirations -Increasing systolic blood pressure Cushing's triad consists of bradycardia, irregular respiration, and a widening pulse pressure (increasing systolic pressure). The pulse is full and bounding, not weak. The systolic blood pressure increases, not decreases.
A patient underwent cranial surgery. What actions should the nurse perform to prevent increased intracranial pressure (ICP)? Select all that apply.
-Turn and position the patient appropriately -Frequently assess the patient's neurologic status -Closely monitor fluid and electrolyte levels and serum osmolality The patient should be turned and positioned appropriately and carefully to prevent increase in ICP. Frequent assessment of the patient's neurologic status is essential during the first 48 hours after the cranial surgery. Close monitoring of fluid and electrolyte levels and serum osmolality are done to detect changes in sodium regulation, the onset of diabetes insipidus, or severe hypovolemia. Assessing the patient's weight loss after surgery and monitoring the patient's serum creatinine and lipid profile are not the prime interventions after any cranial surgery because they do not affect the ICP. STUDY TIP: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.
A dose of dexamethasone 8 mg intravenous (IV) is prescribed. The unit stock medication has a concentration of 20 mg/mL. How many milliliters will the nurse will draw up to administer this dose? Record your answer using one decimal place. Insert a leading zero if applicable. ________ mL
0.4 Using the medication-calculation equation of dose desired (8 mg) divided by dose on hand (20 mg) and multiplied by the quantity (1 mL), the answer is 0.4 mL.
A nurse is educating a patient's family about intracranial pressure (ICP). The nurse explains that normal ICP is a balance of which three components?
Blood pressure, brain tissue, and cerebrospinal fluid Normal ICP involves a balance of blood pressure, brain tissue, and cerebrospinal fluid. The ventricles of the brain, glucose level, and body mass index do not contribute to maintaining normal ICP.
The nurse is maintaining a propofol drip in the intensive care unit for a patient on a mechanical ventilator. What does the nurse inform the family about the benefit of the drug regarding managing anxiety and agitation?
It has a short half-life and rapid onset of action. Intravenous (IV) anesthetic propofol has gained popularity in management of anxiety and agitation because it has a short half-life, which facilitates faster therapeutic action of the drug in the body. The side effect of propofol is hypotension, and it limits the use of propofol in hypotensive patients. Propofol does not have effect on fluid replacement or electrolyte balance in the body.
A patient presents with a shunt malfunction related to increased intracranial pressure (ICP). On examination, which findings would the nurse observe? Select all that apply
-Blurred vision -Headache and vomiting -Decreased level of consciousness Blurred vision, headache and vomiting, and a decreased level of consciousness are manifestations of shunt malfunction related to an increase in ICP. Cough and gaseous distention are not relevant.
Decerebrate posture is documented in the chart of the patient for whom the nurse will be caring. The nurse should know that the patient may have elevated intracranial pressure (ICP), causing serious disruption of motor fibers in the midbrain and brainstem, and will expect the patient's posture to look like which posture represented below?
2 Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury.
A nurse is caring for a patient with a brain injury as a result of a car accident. On admission, the patient's vital signs are blood pressure (BP), 132/72; pulse 100 beats/minute; and respirations 24. Later, the nurse reassesses the patient's vital signs. Which set of vital signs should the nurse report to the physician immediately?
Blood pressure 172/54, pulse 58 beats/minute, respirations 10 Fluctuations in vital signs are expected. The nurse will report a blood pressure of 172/54, pulse of 58 beats/minute, and respiration rate of 10, because these values may indicate Cushing's triad, or systolic hypertension with a widening pulse pressure, bradycardia, and irregular or low respirations. This is indicative of increased intracranial pressure. BPs of 136/84, 126/68, and 112/56; pulses of 88, 110, and 98; and respiration rates of 26, 32, and 28 are not values linked to ICP.
The nurse is administering mannitol intravenously to a patient with a head injury. Which assessment will help the nurse determine if the medication is having the desired outcome?
Decreased intracranial pressure Mannitol is given to decrease intracranial pressure, so measuring this will determine the effectiveness of the drug. Serum blood glucose, blood pressure, and body temperature will may be measured, but these will not determine the effectiveness of the mannitol.
A patient with increased intracranial pressure (ICP) is prescribed a high dose of barbiturates. What outcome does the nurse anticipate the patient will have after administration of the medication?
Decreases cerebral metabolism High doses of barbiturates are used in patients with increased intracranial pressure. Barbiturates decrease cerebral metabolism, helping to reduce ICP. Corticosteroids are used to reduce vasogenic edema. Mannitol acts to decrease ICP through plasma expansion and osmotic effect. Hypertonic saline solution causes massive movement of water out of the brain cells into the blood vessels. Test-Taking Tip: Recall the actions and uses of barbiturates to answer this question accurately.
A nurse should assess pupillary response in a patient with a head trauma and suspected intracranial pressure to evaluate the functioning of which cranial nerve?
III Cranial nerve III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. Cranial nerve XII controls tongue movement, cranial nerve X is the vagus nerve, and cranial nerve V is the trigeminal nerve.
After assessing the patient, the nurse declines to administer mannitol to the patient. Which condition supports this nursing intervention?
Increased serum osmolality Mannitol increases osmotic effect and may cause neurologic complications; it is contraindicated in a patient with increased serum osmolality. Mannitol is used to treat cerebral edema, cerebral tissue swelling, and increased ICP because of its diuretic effect.
A patient who sustained a head injury in a motorcycle crash has a baseline Glasgow Coma Scale (GCS) score of 14. The nurse recognizes signs of increasing intracranial pressure on the basis of what assessment findings?
Increased systolic blood pressure, decreased pulse, widening pulse pressure, GCS score of 4 One classic sign of increasing intracranial pressure and neurologic deterioration is increased systolic blood pressure and decreased diastolic blood pressure (resulting in a widening pulse pressure) accompanied by bradycardia. Hypertension, bradycardia, and bradypnea together are known as the Cushing's triad. Increased systolic blood pressure, increased pulse, and GCS of 12 and decreased diastolic blood pressure, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic blood pressure, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the blood pressure and pulse may be stable, the GCS has decreased from 14 to 9. A GCS of 15 is the best score, reflecting a fully awake, alert, and oriented patient. Anything less than 8 is considered a coma.
A nurse is providing a community presentation on causes of brain injury. Which would the nurse include as possible causes for increased intracranial pressure?
Subdural hematoma A subdural hematoma is a collection of blood between the brain and its covering, which can cause intracranial pressure. Sinusitis is a respiratory disorder, which would not cause increased intracranial pressure. Cor pulmonale is a cardiorespiratory disorder, which would not affect intracranial pressure. Diabetes insipidus is an endocrine disorder affecting glucose regulation, not intracranial pressure.
A nurse is caring for a patient with a traumatic brain injury and increased intracranial pressure (ICP). Which symptom would the nurse report to the physician immediately?
Urine output of 1000 mL in 1 hr An increased urine output of 1000 mL in one hour could cause critical fluid and electrolyte imbalance issues and needs prompt attention; this indicates a decline in the patient's condition. An ICP of 20 mm Hg, respiratory rate of 24, and pulse of 100 beats/minute do not indicate a need for the nurse to call the physician.
The patient with increased intracranial pressure (ICP) resulting from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient?
Use strict aseptic technique with dressing changes The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as prescribed. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.
The nurse is caring for a patient with increased intracranial pressure (ICP). What seizure precautions should the nurse take to protect the patient? Select all that apply.
-Keep suction equipment readily available -Use padded side rails and maintain an airway at the bedside -Use prophylactic antiseizure therapy during first seven days after injury. Using padded side rails helps to prevent injury from falling. Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Prophylactic antiseizure therapy can be used during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate his condition; therefore, the environment should be quiet. Seizure treatment should be used prophylactically; instead of waiting for the confirmation of diagnosis or the seizures to happen, the nurse should administer antiseizure treatment in such a situation.
Which nursing intervention is the priority when caring for a patient who has increased intracranial pressure (ICP)?
Continuous ICP monitoring Because ICP is a dangerous condition, the nurse must monitor it constantly. Patients with ICP need to be in a semi-Fowler's, not supine, position. The administration of D5W IV fluids will decrease serum osmolality and increase, not decrease, intracranial pressure. Opiates such as morphine and fentanyl are rapid acting and have little effect on cerebral perfusion, though the patient's respiratory status must be monitored closely.
The nurse assesses a comatose head-injured patient and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. How can the findings be described?
Decorticate posturing Decorticate posturing, described as flexion of the arms, wrists, and fingers and adduction of the upper extremities, indicates damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The assessment findings described are not specifically related to a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. Decerebrate posturing is described as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing, which may indicate more serious damage, results from disruption of motor fibers in the midbrain and brainstem.
What inflammatory condition is the most common cause of acute nonepidemic encephalitis?
Herpes simplex virus encephalitis Herpes simplex virus encephalitis is the most common cause of acute nonepidemic viral encephalitis. St. Louis encephalitis, eastern equine encephalitis, and western equine cause epidemic encephalitis.
The nurse is caring for a patient experiencing increased intracranial pressure (ICP). What is the priority nursing action in the care of this patient?
Monitor fluid and electrolyte status carefully Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors typically are not administered in the treatment of ICP. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
The nurse is performing a neurologic assessment for a patient. When performing a palmar drift test, what is the nurse attempting to determine?
Strength of the hands A palmar drift test is an excellent measure of the strength in the upper extremities. In this test, the patient extends their arms up in front of the body, with eyes closed. Eye movements are tested by examining the cranial nerve functioning. Pupillary reactions are tested with a penlight. Strength of legs is tested by asking the patient to pull the knees up in bed. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.
The novice nurse is assigned a patient who was admitted earlier in the day with a diagnosis of post-head injury concussion. What statement made by the nurse demonstrates an understanding of the care of the patient's injuries?
"I need to assess the patient's level of consciousness frequently because that is the first indication of complications." The first indication of increased intracranial pressure (ICP) is a change in the patient's level of consciousness. Pupil changes are not an immediate assessment finding following a concussion; in fact, pupil changes often are a late sign of neurologic complications. Keeping the patient awake following a head injury is not necessary. Arousing the patient frequently to assess arousal and level of consciousness is an appropriate plan of care following a head injury. Although headache can be common following a head injury, narcotics are avoided in pain management because they can mask the signs of impending complications, particularly alteration in level of consciousness.
A patient presents with a shunt malfunction related to increased intracranial pressure (ICP). On examination, which findings would the nurse observe? Select all that apply.
-Blurred vision -Headache and vomiting -Decreased level of consciousness Blurred vision, headache and vomiting, and a decreased level of consciousness are manifestations of shunt malfunction related to an increase in ICP. Cough and gaseous distention are not relevant.
The nurse is planning the care for a patient with increased intracranial pressure (ICP). What actions should the nurse plan to perform to provide the most comfort for the patient? Select all that apply.
-Minimize procedures that can produce agitation. -Observe the patient for signs of agitation or irritation -Make the patient remain in a quiet and calm environment. When managing the patient with increased ICP, procedures that can produce agitation should be avoided. The patient should be observed for signs of agitation or irritation. The environment should be quiet and calm to provide minimal stimulation to the patient. The stimulation levels should be decreased, and patient's family should be instructed to decrease stimulation and reduce noise, including not visiting too frequently. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.
Which outcomes indicate effective treatment in a patient with increased intracranial pressure who underwent a tracheostomy to help maintain adequate ventilation? Select all that apply.
-PaO2 of the patient is 110 mm Hg -PaCO2 of the patient is 40 mm Hg The goal of maintaining adequate ventilation through tracheostomy is to maintain PaO2 of the patient greater than or equal to 100 mm Hg with PaCO2 in the range of 35 to 45 mm Hg. Therefore the PaO2 and PaCO2 values of 110 and 40 mm Hg indicate effective treatment. A PaO2 of less than 100 and PaCO2 of less than 35 mm Hg indicate ineffective treatment.
The nurse suspects a patient has increased intracranial pressure. Which assessment findings may indicate this condition? Select all that apply.
-The patient is experiencing hemiplegia -The patient has unilateral pupil dilation -The patient is vomiting without preceding nausea Unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial pressure. A patient with increased intracranial pressure would likely have an impaired level of consciousness rather than being alert and oriented. He or she would also have an irregular, not regular, respiratory rate.
A nurse assesses the intracranial pressure (ICP) of a patient with head trauma. The nurse compares the assessment data with which normative value for ICP?
5 to 15 mm Hg A normal intracranial pressure (ICP) reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention.
The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)?
Bradycardia -Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure (not hypotension) with a widening pulse pressure (not narrowing), bradycardia with a full and bounding pulse, and irregular respirations (not tachypnea). Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.
One of the unlicensed assistive personnel (UAP) reports the following vital signs (VS) obtained from a patient with a suspected brain injury: temperature = 101.6° F orally, heart rate = 58, R = 14, and blood pressure = 162/48. What is the nurse's priority response?
Compare the current VS to baseline VS recorded Change in vital signs is caused by increasing pressure on the thalamus, hypothalamus, pons, and medulla. Manifestations, such as Cushing's triad (systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations), are often late signs of markedly increased intracranial pressure (ICP). The nurse should compare the vital signs obtained with baseline vital signs recorded. If there is a deviation from baseline, the nurse should assess the patient, including a repeat set of VS to validate findings. More than just the blood pressure can change with increased intracranial pressure; therefore, asking the UAP to repeat the blood pressure only will not provide any further data. An elevated temperature in a patient with a head injury may indicate a hypothalamic response from injury. The nurse should gather all assessment data before administering antipyretic.
A patient with increased intracranial pressure (ICP) will undergo lumbar puncture for cerebrospinal fluid (CSF) drainage. In which order are the necessary actions performed for intermittent CSF drainage?
Reading that the ICP is above the indicated level is the first step. If ICP is above the indicated level, opening the ventriculostomy system at the indicated ICP is the next step. Once the stopcock is opened, allowing CSF to drain for two to three minutes helps to relieve the pressure in the cranial vault. Closing the stopcock to return the ventriculostomy to a closed system is the final step.