EDAPT Nursing Care: Altered Intracranial Regulation
Which focused assessment finding should indicate to the nurse that the client's intracranial pressure (ICP) is increasing? Select all that apply.
- Slow responses to questions - Unequal pupils - Irritability
What is the cerebral perfusion pressure of a client that has a blood pressure of 180/90 mmHg and an intracranial pressure of 35 mmHg?
85 mmHg
A client admitted with increased intracranial pressure (↑ICP) begins having seizures. Which action should the nurse take first?
Administer lorazepam IV push as needed for seizures.
Upon admission, a client who has a head injury has the following baseline vital signs: blood pressure 126/70 mmHg, heart rate of 110 beats per minute and respiratory rate of 25 breaths per minute. Which set of vital signs, if taken an hour later, will be the most concerning to the nurse?
Blood pressure 156/40 mmHg, pulse 55 beats/min, respirations 12 breaths/min
Based on the unequal pupil size, the nurse should recognize that the client is at highest risk for developing which two complications?
Coma Widened pulse pressure
What impact does mean arterial pressure have on intracranial regulation?
High mean arterial pressure may indicate a high intracranial pressure in a susceptible client.
The nurse anticipates the healthcare provider will order which medication to reduce intracranial pressure (ICP) by increasing urinary output?
Mannitol
Drag and drop the class for each medication and the action it uses to improve intracranial regulation.
Mannitol - Osmotic diuretic - Reduces cerebral edema Methylprednisone - Corticosteroid - Reduces inflammation Morphine sulfate - Opioid - Reduces pain Ceftriaxone - Antibiotic - Reduces infection Lorazepam - Benzodiazepine - Reduce seizure activity Acetaminophen - Prostaglandin inhibitor - Reduces fever
Upon admission to the intensive care unit, the client has a fever of 102 °F (38.9 °C) and states he is getting a bad headache, rating it 8/10. Which orders should the nurse implement now? Select all that apply.
Monitor the client's response to the pain medication. Apply cardiac monitor and automated blood pressure cuff. Administer acetaminophen intravenously (IV).
Review the following nursing diagnoses (left side). Match the correct nursing action (right side) that addresses each diagnosis.
Pain - Comfort measures Impaired mobility - Mobility assistance Altered gas exchange -Emergency airway equipment available Impaired airway clearance - Head of the bead at 30 degrees Imbalanced body temperature - Temperature control measures Impaired swallowing -Feeding assistance
The client is admitted due to a head injury and is experiencing cerebral edema. What is the most appropriate nursing action to stabilize the client?
Raise the client's head off the bed to 30 degrees.
Which priority action should the nurse take when preparing a client for electroencephalography (EEG)?
Withhold lorazepam.
The client is admitted due to altered intracranial regulation. The client has cranial nerve IX and X dysfunction. What should the nurse do first?
Withhold oral fluids and food immediately.
How should the nurse assess the client's cranial nerve V (trigeminal)?
open mouth against resistance
The nurse understands this client is at risk of developing _____________ due to ______________
projectile vomiting increased ICP
The client had a positive Romberg test. What is the priority nursing diagnosis?
risk for fall
