Altered Intracranial Regulation - Nursing Care: Altered Intracranial Regulation

The client is admitted due to altered intracranial regulation. The client has headache and the temperature of 102 degrees Fahrenheit. What are the most appropriate nursing actions? Select all that apply.

1. Administer opioids every 4 hours for pain as needed. 2. Provide a quiet, non-stimulating environment. 3. Administer acetaminophen IV every 4 hours as needed. 4. Monitor the headache and assess by using PQRST scale.

Drag and drop the class for each medication and the action it uses to improve intracranial regulation. ​

1. Class: Osmotic diuretic , Corticosteroid, Opioid, Antibiotic, Benzodiazepine, Prostaglandin inhibitor ​ 2. Action for Intracranial Regulation​: Reduces cerebral edema ​, Reduces inflammation ​, Reduces pain ​, Reduces infection, Reduces seizure activity ​, Reduces fever ​

Review the following nursing diagnoses (left side). Match the correct nursing action (right side) that addresses each diagnosis.

1. Pain - Comfort measure 2. Impaired mobility - Mobility assistance 3. Altered gas exchange - Head of the bed at 30 degrees​ 4. Impaired airway clearance - Emergency airway equipment available 5. Altered cognition - Quiet non-stimulating environment 6. Imbalanced body temperature - Temperature control measures 7. Impaired swallowing - Feeding assistance

What is the cerebral perfusion pressure of a client that has a blood pressure of 180/90 mm Hg and an intracranial pressure of 35 mm Hg?

85 mm Hg

What impact does a mean arterial pressure have on intracranial regulation?

A high mean arterial pressure may indicate a high intracranial pressure in a susceptible client.

The client is admitted due to head injury. The client had episodes of seizures. What will be the most appropriate nursing action?

Administer lorazepam IV push as needed for seizures.

How should the nurse assess the client's cranial nerve V (trigeminal)?

Ask the client to open mouth against resistance.

Upon admission, the client who has head injury has the following baseline vital signs; blood pressure 126/70 mm Hg, 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 mm Hg, pulse 55 beats/min, respirations 12 breaths/min

A client who has ischemic stroke is confused and very anxious. Which nursing action will be included in the plan of care?

Encourage the significant other to remain at bedside.

The client that has episodes of altered intracranial regulation will undergo positron emission tomography (PET) scan. What should the nurse instruct the client prior the procedure?

Have a client empty their bladder.

The client will undergo cerebral angiography early in the morning. What is the most important assessment finding that needs immediate attention?

History of heart failure

The client is admitted due to head injury, and experiencing cerebral edema. What is the most appropriate nursing action to stabilize the client?

Raise the client's head of the bed to 30 degrees.

The client is admitted due to traumatic head injury. The healthcare provider ordered mannitol intravenously. What is the primary reason for administering this medication?

Reduce intracranial pressure

The client had a positive Romberg test. What is the priority nursing diagnosis?

Risk for fall

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.

The client is schedule to have electroencephalography. What should the nurse instruct the client prior the procedure?

Withhold some medications like anti-seizure medication.