Increased Intracranial Pressure
A nurse is caring for a patient with increased ICP due to a subdural hematoma. Upon assessment, the nurse notes one pupil is 3mm and the other is 7mm. Which action should the nurse take next? Assess the patient's lung sounds. Notify the health care provider. Assess the cranial nerves for abnormalities. Document findings in the patient's medical record.
Assess the patient's lung sounds. The nurse would assess the patient for signs of respiratory compromise, but that would not be the nurse's next action. Notify the health care provider. The nurse would notify the health care provider, but that would not be the nurse's next action. Assess the cranial nerves for abnormalities. The nurse would complete a full neurological exam including assessment of the cranial nerves. Document findings in the patient's medical record. The physical assessment findings should be documented, but that would not be the nurse's next action.
The nurse is caring for a patient with a brain tumor and increased intracranial pressure. The initial vital signs were BP 128/88, HR 106, RR 22, Oxygen saturation 98%. Which follow-up vital signs would indicate worsening ICP? BP 116/82, HR 85, RR 20, oxygen saturation 97%BP 172/98, HR 64, RR 24, oxygen saturation 99%BP 98/76, HR 85, RR 12, oxygen saturation 90%BP 135/86, HR 112, RR 10, oxygen saturation 89%
BP 116/82, HR 85, RR 20, oxygen saturation 97% BP 116/82, HR 85, RR 20, oxygen saturation 97% do not indicate worsening ICP. BP 172/98, HR 64, RR 24, oxygen saturation 99% BP 172/98, HR 64, RR 24, oxygen saturation 99% is characteristic of Cushing's triad, elevated BP and decreased HR, indicating worsening ICP. BP 98/76, HR 85, RR 12, oxygen saturation 90% BP 98/76, HR 85, RR 12, oxygen saturation 90% do not indicate worsening ICP. BP 135/86, HR 112, RR 10, oxygen saturation 89% BP 135/86, HR 112, RR 10, oxygen saturation 89% do not indicate worsening ICP.
Which components can affect a patient's increased intracranial pressure? Select all that apply. Blood Brain tissue Hematoma Synovial fluid Cerebrospinal fluid
Blood Blood is a component housed in the skull. The balance among the three components housed in the skull maintains the intracranial pressure. Brain tissue Brain tissue is a component housed in the skull. The balance among the three components housed in the skull maintains the intracranial pressure. Hematoma Hematomas can occur within the brain tissue and between the brain layers. A hematoma in the brain can lead to an increase in intracranial pressure. Synovial fluid Synovial fluid is not a component housed in the skull. The amount of synovial fluid has no effect on intracranial pressure. Cerebrospinal fluid CSF is a component housed in the skull. The balance among the three components housed in the skull maintains the intracranial pressure.
Which nursing assessment can indicate the presence of increased intracranial pressure? Capillary refill Lung sounds Pain assessment Pupillary assessment
Capillary refill The nurse would assess capillary refill in a patient with increased ICP, but that does not indicate the presence of ICP. Lung sounds The nurse would auscultate lung sounds in a patient with increased ICP, but lung sounds do not indicate ICP is present. Pain assessment Patients with increased ICP may experience a headache, but this does not necessarily indicate ICP is present. Pupillary assessment Pressure on the cranial nerves causes fixed pupils in patients with increased ICP. Brisk pupil constriction is a normal finding and is not expected with increased ICP.
A nurse is caring for a patient after resection of a temporal lobe tumor. The patient begins to complain of headache and nausea. Which action should the nurse take? Give oral mannitol Administer an IV fluid bolus Elevate head of patient's bed Administer narcotic pain medicine
Give oral mannitol The patient's symptoms indicate increased ICP, but mannitol is administered IV; it is not an oral medication. Administer an IV fluid bolus The patient's symptoms indicate increased ICP. Giving a large volume of fluids can further increase the patient's ICP and should not be done. Elevate head of patient's bed Elevating the head of the bed allows for appropriate drainage of CSF and is helpful for the patient with increased ICP. Administer narcotic pain medicine Narcotic pain medication would help treat the patient's headache, but could mask signs of altered level of consciousness related to increased ICP. The nurse would not give sedating medications.
Which physiologic event leads to decreased oxygen and death of the brain cells? Tissue edema Excessive hydration Decreased cerebral blood flow Accumulation of carbon dioxide
Tissue edema Tissue edema precedes tissue death, but is not the cause of decreased cerebral oxygen and death of the brain cells. Excessive hydration Excessive hydration does not cause decreased cerebral oxygen and brain tissue death. Decreased cerebral blood flow Decreased cerebral blood flow from compression of cerebral blood vessels leads to decreased oxygen and brain tissue death. Accumulation of carbon dioxide Accumulation of carbon dioxide follows from brain tissue death, and is not the cause of decreased cerebral oxygen and brain tissue death.
The nurse is caring for a patient who sustained major head trauma after a motor vehicle collision. The patient's lab values reveal a BUN of 47, creatinine of 3.1, hemoglobin of 6.8 and potassium level of 6.1. Which provider order would the nurse question? Transfuse PRBC Give Mannitol IV Give Oral Kayexalate Maintain HOB at 30-degrees
Transfuse PRBC The patient's hemoglobin indicates anemia and the need for a blood transfusion. The nurse would not question this order. Give Mannitol IV Mannitol is an osmotic diuretic given to decrease ICP; however, it is contraindicated in patients with renal failure. The patients elevated BUN and creatinine indicate the presence of acute renal failure. The nurse would question this order. Give Oral Kayexalate Kayexalate is given to decrease serum potassium in patients with hyperkalemia. A potassium of 6.2 is hyperkalemia. The nurse would not question this order. Maintain HOB at 30-degrees Patients with major head trauma are at risk for increased ICP. The nurse would maintain the head of bed in a Fowler's position, and would not question this order.
A patient presents with abnormal extension, does not open their eyes to stimulus, and does not give a sound as reaction to pain. The patient exhibiting these signs would be given a score of _____ using the Glasgow Coma Scale. Use numbers only.
4 According the Glasgow Coma scale abnormal extension receives a 2, lack of eye opening receives a 1, and lack of sound to stimuli receives a 1, for a total of 4.
The nurse is caring for a patient with headache, blurred vision, nausea, and vomiting after being struck with a baseball bat during a game. The nurse notes elevated blood pressure and confusion. CT reveals a subdural hematoma. Which provider order would the nurse implement first? Administer Lasix 4 mg Prep patient for cranioplasty Prep patient scalp for burr holes Administer IV normal saline bolus
Administer Lasix 4 mg The nurse would not administer a diuretic because dehydration can lead to further complications in patients with increased ICP. Prep patient for cranioplasty The CT scan indicates a subdural hematoma. A Cranioplasty is not used to relieve pressure from hemorrhage due to a subdural hematoma and would not be indicated for this patient. Prep patient scalp for burr holes The nurse would anticipate the need to create burr holes to evacuate blood from the subdural hematoma. Administer IV normal saline bolus The patient exhibits signs of increased ICP. Nurse would not administer an IV bolus because extra fluids can cause an increase in the patient's ICP.
Identify the physiologic events which can lead to increased intracranial pressure and accumulation of CO2. Select all that apply. Brain abscess Occipital tumor Hyperventilation Subdural hematoma Bacterial meningitis Blunt force trauma to the head
Brain abscess Brain abscesses cause increased ICP and can lead to hypercapnia. Occipital tumor Brain tumors regardless of location can cause increased ICP and can lead to hypercapnia. Hyperventilation Hyperventilation causes hypocapnia. Subdural hematoma Subdural hematoma causes increased ICP and can lead to hypercapnia. Bacterial meningitis Bacterial meningitis causes inflammation and increased ICP and can lead to hypercapnia. Blunt force trauma to the head Brain injury causes increased ICP and can lead to hypercapnia.
During the assessment of a patient with a head injury from a fall, the patient reports a sudden severe headache, nausea and vomiting. The nurse notes right sided weakness, slurred speech and a right facial droop. For which collaborative care procedure would the nurse expect to prepare the patient? Burr holes Craniectomy Cranioplasty Sterotactic procedures
Burr holes Burr holes are used to remove localized fluid and blood beneath the dura, such as may occur from a hemorrhage. Craniectomy Craniectomies are used for excision into the cranium to cut away bone flap and are more appropriate for brain swelling than hemorrhaging. Cranioplasty Cranioplasty is used to repair of cranial defect resulting from trauma, malformation, or previous surgical procedure, not to relieve pressure from a hemorrhage. Sterotactic procedures Sterotactic procedures are used to obtain biopsy, radiosurgery, or dissection, not to relieve pressure from a hemorrhage.
The nurse is administering IV dexamethasone to a patient with a frontal lobe tumor who reports left upper quadrant pain, nausea and vomiting. Upon assessment, the nurse notes coffee ground emesis and tenderness on palpation. Which provider order would the nurse anticipate? IV protonix PO antibiotics Insert NG tube Obtain hemoccult
IV protonix IV protonix is administered with corticosteroids to prevent GI bleeding. This patient may receive protonix, but it will not correct the patient's current problem. PO antibiotics Antibiotics are administered to kill infectious organisms, not to treat GI bleeding. Insert NG tube The nurse would expect to insert a NG tube to decompress the stomach in a patient with active GI bleeding to prevent aspiration. Obtain hemoccult A hemoccult would determine the presence of lower GI bleeding. However, a GI bleed has been confirmed and obtaining a hemoccult will not correct the patient's current problem.
During assessment of a patient with a basilar skull fracture resulting in intracranial pressure (ICP), the nurse notes a cluster breathing pattern. The patient is otherwise stable with a BP of 115/76, HR of 88 and an abdominal exam that shows no distension and soft bowel sounds throughout. Which action should the nurse take? Increase IV fluids. Insert a nasogastric tube. Administer opioid pain medication. Reposition the patient by elevating the head of bed.
Increase IV fluids. Patients with increased ICP should remain normovolemic initially, then may require osmotic diuresis. Additional IV fluid puts the patient at risk for volume overload which may worsen the already abnormal breathing pattern. Insert a nasogastric tube. A nasogastric tube is inserted to decrease abdominal distension and the risk of vomiting with aspiration. This patient has a normal abdominal exam, but an abnormal breathing pattern. The nursing intervention must address the breathing issue. Administer opioid pain medication. Based on the patient's vital signs, there is not an indication of pain. Administration of opioid pain medication may worsen the abnormal breathing pattern, due to its side effect of respiratory depression. Reposition the patient by elevating the head of bed. Repositioning the patient and elevating the head of the bed will facilitate drainage of cerebral spinal fluid (CSF). This will help decrease ICP and facilitate a more normal, life sustaining breathing pattern.
A nurse is assisting the provider during a neurological assessment on an unconscious adult patient with increased intracranial pressure. When holding the eyelids open and moving the patient's head to the right side, the eyes move to the right side. How would the nurse report this finding? Ipsilateral damage Normal Moro reflex Negative oculovestibular reflex Abnormal oculocephalic reflex
Ipsilateral damage Ipsilateral damage means damage on the affected side. It is not specific to eye assessment. Normal Moro reflex The moro reflex is seen in newborns and should not be present in adults. Negative oculovestibular reflex The oculovestibular reflex is tested by elevating the Head of the bed 30 degrees placing iced water into the external ear canal. The nurse would not document findings this way. Abnormal oculocephalic reflex Oculocephalic reflex, or the dolls eye reflex, is tested by turning the patient's head briskly to the left or right while holding the eyelids open. A normal response is movement of the eyes across the midline in the direction opposite that of the turning.
Which diagnostic studies would be performed in order to determine whether internal bleeding is present in a patient with increased intracranial pressure? Select all that apply. MRI Burr hole Craniotomy Infrascanner Toxicology screen
MRI MRI provides an image of the brain to determine if bleeding or a mass is present in the brain. Burr hole A Burr hole procedure would be performed to remove blood that was already detected. It would not determine whether or not bleeding is present. Craniotomy A craniotomy would be performed to decrease intracranial pressure, not to determine whether or not there is internal bleeding. Infrascanner An infrascanner can be used to detect intracranial bleeding. Toxicology screen A toxicology screen may be ordered for patients with head injuries, but would not determine whether internal bleeding is present.
Why is nutrition an important part of the collaborative care of a patient with increased intracranial pressure? Malnutrition promotes cerebral edema Mild dehydration is preferable in early stages Serum osmolarity must decrease to decrease ICP Glucose levels must remain constant to decrease ICP
Malnutrition promotes cerebral edema Malnutrition causes a decrease in albumin related to low protein intake. This increases the fluid shift that causes cerebral edema. Mild dehydration is preferable in early stages The patient should remain normovolemic to prevent worsening of ICP and mild dehydration is not beneficial for patients with increased ICP. Serum osmolarity must decrease to decrease ICP Patient intake does effect osmolarity, but decreased serum osmolarity increases, not decreases, cerebral edema, and would not be beneficial for the patient with increased ICP. Glucose levels must remain constant to decrease ICP Patient glucose levels should be assessed, because a state of increased ICP increases the need for glucose. However, glucose levels remaining constant will not decrease a patient's ICP.
A patient with increased intracranial pressure is being treated. Which medications can be given simultaneously in order to decrease this patient's increased ICP? Select all that apply. Morphine Mannitol Protonix Acetaminophen Hypertonic saline
Morphine Morphine may be given to patients with ICP for pain management, but does not decrease ICP. Mannitol Mannitol can be given in combination with another medication to treat increased ICP in severe cases. Protonix Protonix is an antihistamine. It is given along with Corticosteroids to prevent GI ulcers, not treat increased ICP. Acetaminophen Acetaminophen is an antipyretic, and is not used to treat increased ICP. Hypertonic saline Hypertonic saline is given in combination with another medication to decrease ICP in severe cases.
A nurse is monitoring a patient with increased intracranial pressure using a ventriculostomy. The patient's ICP monitor indicates that the P2 wave is higher than the other waves. Which provider order would the nurse anticipate? Provide an IV fluid bolus. Administer IV mannitol. Prepare for surgery. Maintain patient supine.
Provide an IV fluid bolus. The When P2 wave depicting relative brain volume is higher than the other waves, it indicates a high ICP with compromised intracranial compliance. The nurse would not provide an IV bolus because the additional fluids would further raise the ICP. Administer IV mannitol. When P2 wave depicting relative brain volume is higher than the other waves, it indicates a high ICP with compromised intracranial compliance. Mannitol would not fix the impaired ventriculostomy. Prepare for surgery. When P2 wave depicting relative brain volume is higher than the other waves, it indicates a high ICP with compromised intracranial compliance. The nurse would expect to prepare the patient for surgery to assess/reposition the ventriculostomy tube. Maintain patient supine. When P2 wave depicting relative brain volume is higher than the other waves, it indicates a high ICP with compromised intracranial compliance. Placing the patient in a supine position would further increase the ICP.
The nurse is caring for a patient with increased ICP after a motor vehicle collision. Which physical assessment findings would be a late sign of herniation into the brainstem? Syncopal episodes Nausea and vomiting Sustained periods of apnea Severe pain in the occipital area
Syncopal episodes Syncope is a symptom of head injury and increased ICP, but does not indicate herniation into the brain stem. Nausea and vomiting Nausea and vomiting are symptoms of head injury and increased ICP, but do not indicate herniation into the brain stem. Sustained periods of apnea Apnea is a late sign of herniation into the brain stem. If compression of the brain stem is unrelieved, the patient will suffer respiratory arrest. Severe pain in the occipital area Headache is a symptom of head injury and increased ICP, but does not indicate herniation into the brain stem.
