Increased Intracranial Pressure

Romberg's test

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

First sign of increased intracranial pressure

Altered Consciousness an increase in intracranial pressure causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased level of consciousness. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and the medulla, resulting in a slow pulse. A widening pulse pressure occurs because of an increase in systolic pressure. As the intracranial pressure increases it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in irregular respirations that progress to deep, rapid breathing alternating with periods of apnea (Cheyne-Stokes respirations).

early signs of ICP

In a child, include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures.

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- Early signs and symptoms may be subtle - As pressure increases, signs and symptoms become more pronounced and the level of consciousness (LOC) deteriorates

Which assessment finding alerts the nurse to suspect increased intracranial pressure in an infant?

Projectile vomiting Increased intracranial pressure exerts pressure on the vomiting center in the brain, resulting in projectile vomiting unrelated to feeding. The eyeballs will show signs of increased fluid volume in the skull and will be pushed forward, pulling the lids taut. The fontanels will show signs of increased fluid volume in the skull and will bulge. With increased intracranial pressure the systolic pressure is increased, and the diastolic pressure is the same or decreased, creating a widening, not narrowing, of pulse pressure.

Which of the orientee's interventions would the nurse question when observing an orientee nurse caring for an unconscious client who has increasing intracranial pressure?

Suctioning the endotracheal tube every hour Although suctioning is done when needed to maintain an airway, it is not done routinely on a schedule because it increases intracranial pressure.

Which clinical finding would the nurse recognize as a sign that an infant's intracranial pressure has increased?

Tension of the anterior fontanel The anterior fontanel will be widened and tense because of the increased volume of cerebrospinal fluid. The pulse rate will be decreased with increased intracranial pressure. The reflexes will be hyperactive with increased intracranial pressure. The blood pressure will be higher with increased intracranial pressure.

Kernig's sign

The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

Brudzinski's sign

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

autonomic dysreflexia

The most frequent cause is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A change in vital signs may be a late sign of increased intracranial pressure

Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

evidence of increased intracranial pressure

Vomiting, irritability, and decreased level of consciousness Anorexia, nausea, and vomiting occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness. The blood pressure will be increased, not decreased, because of pressure on the vital centers in the brain. Also, the pulse pressure increases. Pressure on the respiratory center in the medulla results in a decreased, not increased, respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations.

Dexamethasone

a corticosteroid anti-inflammatory agent is used to reduce increased intracranial pressure.

Hemiparesis

a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

Decerebrate posturing

abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

Decorticate posturing

abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

Chlorpromazine

an antipsychotic/ neuroleptic/ antiemetic, can be given safely to a neurologically impaired client for restlessness.

Mannitol

an osmotic diuretic used to reduce increased intracranial pressure.

Morphine

contraindicated for an unconscious, neurologically impaired client because it depresses respirations.

gaze nystagmus

evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs

Late signs of ICP

include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

Bacterial Meningitis diagnosis

is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels

Hydrocephalus

occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure (ICP). In infants , the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Stimulus should be kept at a minimum because of the increase in ICP.

Babinski's test

results in dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.

Head injury

the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP.