NUR265 Exam3
Unit 7
❖ Increased Intracranial Pressure (ICP)
o Pathophysiology: Increased pressure within the head, compresses blood vessels leading to cerebral hypoxia
and can put pressure on the brain stem-killing the patient.
o Causes and Risk Factors: Aneurysm stroke; burst blood vessels that fill up the brain with blood, Head trauma
or Meningitis; increased swelling and inflammation,Tumor;increased brain tissue
▪ Often after head injury
▪ Brain tumors
▪ Bleeding
▪ Toxic and viral encephalitis
o Signs and symptoms
▪ Early sign:
⟶ Altered LOC,Irritability,restless
⟶ Decreased mental status
⟶ Sleepiness
⟶ Flat affect and drowsiness
▪ Moderate sign:
⟶ Headache-constant
⟶ Sudden Vomiting “Emesis”,Without Nausea=Report to HCP!!!
▪ Critical Late sign:
⟶ Cushing Triad
⟶ Wide pulse pressure: HIGH BP “Hypertension”, LOW HR “Bradycardia”, LOW RR “Decreased
Respirations
▪ Late DEADLY signs:
⟶ Lungs: Irregular Respirations, Cheyne Stokes Respirations
⟶ Neck: Nuchal rigidity (stiff neck),Can not FLEX chin toward chest
⟶ Brain stem affected: Eyes
• Pupils “Fixed and dilated”
• Unequal
• 8mm (Normal 2-6mm)
• Dolls eyes: this means brainstem is intact
• If the eyes stay fixed and dilated when the head is turned, it means BRAINSTEM is
affected.
Foot
• Babinski reflex (Toes fan out when stimulated=BAD) means brain stem herniation! Normal
in an infant below 1 year old, NOT NORMAL in adult!
⟶ Seizures and coma
⟶ Abnormal posturing:
− Decorticate: arms flex toward core (ex.ballerina arms down towards core)
− Decerebrate: arms flexed out to sides =far WORSE!(ex.ballerina arms outward)
o Diagnostics:
⟶ Imaging-CT scan
• 1st test-quick easy picture of the brain (Showing the root cause)
• NOT an MRI-they are too long and slow
• NO LUMBAR PUNCTURE (Spinal tap)
• ICP monitoring (for long-term patients)
• Normal ICP:10-15mm
, • High risk of infection!
o Nursing Intervention
⟶ I:Immobilize Head “C-spine”
• Head in neutral position
• Log roll “As one unit”
⟶ C:Co2 Low
• Lower Co2 means lower ICP,Carbon dioxide vasodilates the brain resulting in more swelling
from more blood flow. Hyperventilation decreases co2 by blowing it out
⟶ P:Posturing
• HOB: Semi-fowler’s (30-35 degrees or higher)
• NO flexion and bending extremities
• NO coughing,sneezing,blowing nose
• NO Valsalva maneuvers or holding breath
⟶ S:Suctioning
• 10 seconds or less
• 100% O2 before/after suction
o GCS Score
⟶ 15=highest score
⟶ 8= intubate
⟶ 3=lowest score
⟶ REPORT decreasing GCS score!
o Treatment: Pharmacology
⟶ Phenytoin: prevent seizures
⟶ Steroids: Dexamethasone
⟶ Phenobarbital: a barbiturate to decrease brain activity
⟶ Mannitol: osmotic diuretic #1 drug to know (side effect:edema,s/s of heart failure)
o Questions:
➢ Which client is priority?~Closed head injury waiting for brain imaging who reports a headache and emesis
of 200ml without nausea
➢ Priority assessment findings for a client recovering from a head trauma? Select all that apply
1. Eyes that move in the opposite direction when patient is turned.
2. Extremities that contracted to the core of the body
3. Fixed pupils that remain 8mm when assessed with a pen light
4. Level of consciousness that has not diminished since admission
5. Grips 5/5 bilateral
6. Toes that fan out when the sole of the foot is stroked
➢ Client found on the floor, appearing lethargic, bleeding at the back of head, heart rate of 45 bpm and a blood
pressure of 220/88. First action? Immediate C-spine immobilization and CT scan to rule out intracranial
bleed
➢ Client on ventilator…increased PaCo2.The nurse receives an order to increase the respiratory rate on the
ventilator. This change should have what changes on the patient’s ICP?Decreases the ICP...decrease in
carbon dioxide
➢ Instruct patient to exhale when turning or moving in bed.
➢ Immediate intervention when client with ICP states… I will turn cough, and deep breath”
➢ Interventions for increased ICP? Select all that apply
1) Position-semi fowlers
2) Place neck in neutral position
3) Teach avoid Valsalva maneuver
4) Position avoid flexion of hips,waist,and neck
5) Suction only as necessary but no longer than 10 seconds
➢ Interventions…increased ICP and ineffective breathing pattern? Select all that apply
Unit 7
❖ Increased Intracranial Pressure (ICP)
o Pathophysiology: Increased pressure within the head, compresses blood vessels leading to cerebral hypoxia
and can put pressure on the brain stem-killing the patient.
o Causes and Risk Factors: Aneurysm stroke; burst blood vessels that fill up the brain with blood, Head trauma
or Meningitis; increased swelling and inflammation,Tumor;increased brain tissue
▪ Often after head injury
▪ Brain tumors
▪ Bleeding
▪ Toxic and viral encephalitis
o Signs and symptoms
▪ Early sign:
⟶ Altered LOC,Irritability,restless
⟶ Decreased mental status
⟶ Sleepiness
⟶ Flat affect and drowsiness
▪ Moderate sign:
⟶ Headache-constant
⟶ Sudden Vomiting “Emesis”,Without Nausea=Report to HCP!!!
▪ Critical Late sign:
⟶ Cushing Triad
⟶ Wide pulse pressure: HIGH BP “Hypertension”, LOW HR “Bradycardia”, LOW RR “Decreased
Respirations
▪ Late DEADLY signs:
⟶ Lungs: Irregular Respirations, Cheyne Stokes Respirations
⟶ Neck: Nuchal rigidity (stiff neck),Can not FLEX chin toward chest
⟶ Brain stem affected: Eyes
• Pupils “Fixed and dilated”
• Unequal
• 8mm (Normal 2-6mm)
• Dolls eyes: this means brainstem is intact
• If the eyes stay fixed and dilated when the head is turned, it means BRAINSTEM is
affected.
Foot
• Babinski reflex (Toes fan out when stimulated=BAD) means brain stem herniation! Normal
in an infant below 1 year old, NOT NORMAL in adult!
⟶ Seizures and coma
⟶ Abnormal posturing:
− Decorticate: arms flex toward core (ex.ballerina arms down towards core)
− Decerebrate: arms flexed out to sides =far WORSE!(ex.ballerina arms outward)
o Diagnostics:
⟶ Imaging-CT scan
• 1st test-quick easy picture of the brain (Showing the root cause)
• NOT an MRI-they are too long and slow
• NO LUMBAR PUNCTURE (Spinal tap)
• ICP monitoring (for long-term patients)
• Normal ICP:10-15mm
, • High risk of infection!
o Nursing Intervention
⟶ I:Immobilize Head “C-spine”
• Head in neutral position
• Log roll “As one unit”
⟶ C:Co2 Low
• Lower Co2 means lower ICP,Carbon dioxide vasodilates the brain resulting in more swelling
from more blood flow. Hyperventilation decreases co2 by blowing it out
⟶ P:Posturing
• HOB: Semi-fowler’s (30-35 degrees or higher)
• NO flexion and bending extremities
• NO coughing,sneezing,blowing nose
• NO Valsalva maneuvers or holding breath
⟶ S:Suctioning
• 10 seconds or less
• 100% O2 before/after suction
o GCS Score
⟶ 15=highest score
⟶ 8= intubate
⟶ 3=lowest score
⟶ REPORT decreasing GCS score!
o Treatment: Pharmacology
⟶ Phenytoin: prevent seizures
⟶ Steroids: Dexamethasone
⟶ Phenobarbital: a barbiturate to decrease brain activity
⟶ Mannitol: osmotic diuretic #1 drug to know (side effect:edema,s/s of heart failure)
o Questions:
➢ Which client is priority?~Closed head injury waiting for brain imaging who reports a headache and emesis
of 200ml without nausea
➢ Priority assessment findings for a client recovering from a head trauma? Select all that apply
1. Eyes that move in the opposite direction when patient is turned.
2. Extremities that contracted to the core of the body
3. Fixed pupils that remain 8mm when assessed with a pen light
4. Level of consciousness that has not diminished since admission
5. Grips 5/5 bilateral
6. Toes that fan out when the sole of the foot is stroked
➢ Client found on the floor, appearing lethargic, bleeding at the back of head, heart rate of 45 bpm and a blood
pressure of 220/88. First action? Immediate C-spine immobilization and CT scan to rule out intracranial
bleed
➢ Client on ventilator…increased PaCo2.The nurse receives an order to increase the respiratory rate on the
ventilator. This change should have what changes on the patient’s ICP?Decreases the ICP...decrease in
carbon dioxide
➢ Instruct patient to exhale when turning or moving in bed.
➢ Immediate intervention when client with ICP states… I will turn cough, and deep breath”
➢ Interventions for increased ICP? Select all that apply
1) Position-semi fowlers
2) Place neck in neutral position
3) Teach avoid Valsalva maneuver
4) Position avoid flexion of hips,waist,and neck
5) Suction only as necessary but no longer than 10 seconds
➢ Interventions…increased ICP and ineffective breathing pattern? Select all that apply
