NSG 434 Topic 6 Cerebral Dysfunction
& ICP
Widening of sutures, tense and budging fontanels - answer Sign of increased ICP in a
child with open fontanels
Changes in LOC - answer Earliest indicator of change in neurological status
Full consciousness
Confusion: Impaired decision-making
Disorientation: To time and place
Lethargy: Sluggish speech - answer Changes in LOC in descending order
Eye, verbal, and motor response - answer What 3 parameters are measured by the
GCS?
GCS of 8 or lower - answer Definition of coma
deep coma – answer CGS of 3 or lower indicates
Assess for pupil size and reactivity
Temp is often elevated
HR can be rapid, slow and bounding, or feeble
BP may be normal, elevated or very low
RR is often slow, deep, and irregular – answer Assessment parameters for increased
ICP
Irritability, poor feeding
High-pitched cry, difficult to soothe
Fontanels: Tense, bulging
Cranial sutures: Separated
Eyes: Setting-sun sign
Scalp veins: Distended - answerClinical manifestations of increased ICP in infants
setting sun sign - answeran ophthalmologic sign in young children resulting from
upward-gaze paresis. In this condition, the eyes appear driven downward, the sclera
may be seen between the upper eyelid and the iris, and part of the lower pupil may be
covered by the lower eyelid.
sunset eye sign - answerearly sign of hydrocephalus requiring prompt neuroimaging
and urgent surgical intervention.
& ICP
Widening of sutures, tense and budging fontanels - answer Sign of increased ICP in a
child with open fontanels
Changes in LOC - answer Earliest indicator of change in neurological status
Full consciousness
Confusion: Impaired decision-making
Disorientation: To time and place
Lethargy: Sluggish speech - answer Changes in LOC in descending order
Eye, verbal, and motor response - answer What 3 parameters are measured by the
GCS?
GCS of 8 or lower - answer Definition of coma
deep coma – answer CGS of 3 or lower indicates
Assess for pupil size and reactivity
Temp is often elevated
HR can be rapid, slow and bounding, or feeble
BP may be normal, elevated or very low
RR is often slow, deep, and irregular – answer Assessment parameters for increased
ICP
Irritability, poor feeding
High-pitched cry, difficult to soothe
Fontanels: Tense, bulging
Cranial sutures: Separated
Eyes: Setting-sun sign
Scalp veins: Distended - answerClinical manifestations of increased ICP in infants
setting sun sign - answeran ophthalmologic sign in young children resulting from
upward-gaze paresis. In this condition, the eyes appear driven downward, the sclera
may be seen between the upper eyelid and the iris, and part of the lower pupil may be
covered by the lower eyelid.
sunset eye sign - answerearly sign of hydrocephalus requiring prompt neuroimaging
and urgent surgical intervention.
