Chapter 66: Neurologic Dysfunction

late signs of increased ICP

Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

urinary output as an indicator of diabetes insipidus

An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus

by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg

The CPP (cerebral perfusion pressure) is calculated by?

Monro-Kellie hypothesis

The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called ?

hypertonic solution, like mannitol

With increasing ICP, _____________ solutions, are used to decrease swelling in the brain cells.

Absence seizures

occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements.

Lethargy and stupor (reacting only to loud or painful stimuli)

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

Jacksonian seizure

begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area.

Generalized seizure

causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur.

Sensory seizure

symptoms include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.