Module 6

increased intracranial pressure

5-15 mmHg normal pressure. Anything that causes swelling, bleeding, space occupying will increase this pressure. Results from an increase in intracranial content that occurs with tumor growth, edema, excess cerebrospinal fluid (CSF) or hemorrhage.

3

A nurse assesses the patients LOC using the Glasgow coma scale. What score indicates severe impairment of neurologic function?

Locked in syndrom

A patient has a lesion affecting the pons, resulting in paralysis And the inability to speak, but has vertical I movements and lid elevation this patient is suffering from

Foot drop and paralyzed extremity

Assist with daily active or passive range of motion

Incontinence

Institute of bowel training program

Respiratory distress, pneumonia, aspiration, pressure ulcer, deep vein thrombosis, and contractures

List five potential collaborative problems for a patient with an altered LOC

Foot drop

Maintain dorsiflexion to affected area

Mannitol

The nurse is caring for a patient with increased ICP. As a pressure rises what asthmatic diuretic does the nurse prepare to administer?

Brain herniation resulting in death

The primary lethal complication of ICP is

Lethargy and stupor

What does the nurse recognized as the earliest sign of serious impairment of brain circulation related to increased ICP?

A neurologic examination should include evaluation of mental status, cranial nerve function, cerebellar function, reflexes, and motor and sensory function, as well as the score of the Glasgow coma scale.

When the nurse performs a neurologic examination, what should be included?

Space activities to avoid stress and strain. Maintain a calm atmosphere and decrease environmental stimuli.

When the nurse plans Alixis care, how can his needs be met in order to prevent a rise in ICP and a decrease in CPP?

epidural hematoma

a collection of blood in the space between the skull and dura mater

increased intracranial pressure

a raised level of pressure within the skull above the normal and healthy level

epidural hematoma tx

emergency craniotomy

Increased Intracranial Pressure (ICP)

*HOB = 30-45 degrees (or 15-30??) promotes venous drainage *support in cervical collar or neck rolls *maintain head in midline/neutral position AVOID *neck flexion, head rotation, hip flexion *coughing, sneezing, bending fwd, suctioning

Proper positioning helps reduce ICP. The patient's head is kept in a neutral midline position maintained with the use of a cervical collar if necessary to promote venous drainage. Elevation of the head is maintained at 30 to 45° unless contraindicated. Extreme rotation of the knack and flexion of the knack are avoided, because compression or distortion of the jugular vein's increases ICP. Extreme hip flexion is also avoided, because this position causes an increase in intra-a domino and intra-thoracic pressures, which can produce and increase in ICP.

Alex 830 to use-year-old male was riding his motorcycle without a helmet through with the words and hit a large log ejecting him over the handle bar and into a tree. He was unconscious when his friends found him and called the rescue squad. He has had a craniotomy to relieve an epidural hematoma and is in the neurologic intensive care unit. In order to optimize cerebral perfusion pressure see PCP and decrease intracranial pressure ICP in what position should the nurse maintain Alex?

increased intracranial pressure

An increase in either tissue, CSF or blood will increase pressure in intracranial cavity

Impaired cough reflex, paralyzed diaphragm

Elevate the head of the bed 30°

Before and after suctioning the patient is adequately ventilated to prevent hypoxia

If a patient with an altered LOC requires suctioning what intervention is a priority for the nurse to provide?

Increased Intracranial Pressure (ICP)

Increased pressure in the skull from either an increase in blood volume or CSF, or brain tissue edema, results in less arterial blood entering the high pressure area in the brain s&s severe headache, vomiting, papilledema

Cerebral Adema, pain, seizures, increased ICP and neurologic status

Nursing postoperative management includes detecting and reducing_______ relieving______ preventing______ and monitoring______ and ______

Vasopressin

Patient had a small pituitary adonoma Removed by the transphenoidal approach and has developed diabetes insipidus. What pharmacological therapy will the nurse be administering to this patient to control symptoms?

Impaired cough reflex

Place the patient in a lateral position

More than 200 ml/hr

A nurse is assessing a patients urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly out part of what volume over two hours maybe a positive indicator?

Notify the physician of a possible cerebral spinal fluid leak

A patient three days postoperative from a craniotomy informs the nurse, I feel something trickling down the back of my throat and I taste something salty. What priority intervention does the nurse initiate?

increased intracranial pressure

The conditions in this module will address altered pathways. The most important nursing assessment is that of the level of consciousness. If there is an alteration, the patient might exhibit a decrease in orientation to person, time, or place; may not follow commands appropriately; and may not be alert. This can be a sign of an increase in intracranial pressure and can affect mentation and cognition. There are many factors that can influence altered level of consciousness, including trauma, tumors, seizures, or stroke. Generally, edema occurs on a cellular level, thus disrupting transmission of impulses.

A change in the level of consciousness

The earliest sign of increased ICP is

Increased ICP

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a sub dural 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 the lungs. What does the nurse suspect is occurring?

Maintenance of a patent airway

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

Pneumonia, aspiration, respiratory failure

Three major potential complications in a patient with a depressed level of consciousness are

Brainstem herniation, diabetes insipidus, Syndrome of inappropriate antidiuretic hormone SIADH

Three primary complications of increased ICP are

Stool softeners may be prescribed. When Alex is awake and alert, a high-fiber diet may be indicated. Abdominal distention, which increases intra-a domino and intrathoracic pressure and I CP, should be noted. Enemas and cathartics our avoided if possible. When moving or being turned in bed ask Alex to exhale which opens the quad us to avoid the Valsalva maneuver.

What intervention can the nurse provide to avoid having Alex perform the Valsalva maneuver?

An altered level of consciousness is present when the patient is not orientated does not follow commands, or needs persisted stimuli to achieve a state of alertness. LOC is guaged on a continuum, with a normal state of alertness and full cognition on one end and coma on the other end.

What is meant by an altered level of consciousness?

Alertness is measured by the patient's ability to open the eyes spontaneously or in response to a vocal or noxious stimulus which is pressure or pain.

What is the optimal way to determine the level of a patient's alertness?

epidermal hematoma

is a type of traumatic brain injury (TBI) in which a buildup of blood occurs between the dura mater (the tough outer membrane of the central nervous system) and the skull.