ICP
What to avoid administering in a patient with Increased Intracranial Pressure (IICP)?
D5W
Patient is having a seizure, symptoms as follows: muscle rigidity, incontinence, cyanosis, pupils fixed and dilated, lasts 15-60 seconds. What kind of seizure would the nurse suspect?
Tonic Seizure
Disease that is slow progressive degeneration of the muscles in the foot
Charcot-Marie-Tooth (CMT)
What is normal CPP? How is it calculated?
50-100
CPP=MAP-ICP
Which assessment finding would indicate early increased intracranial pressure?
- Confusion, restlessness
- Fixed, dilated pupils
- Bradycardia
- Positive Babinsky
Confusion, restlessness
The patient is having the following symptoms: opposing muscle contractions, one limb more than the other, hyperventilation, eyes rolling back, frothy sputum, lasts 60-90 seconds. The nurse suspects what kind of seizure?
Clonic Seizure
What is normal ICP?
5-15 SUPINE
(drops when vertical (-10mmHg)
A patient has a MAP of 90 mmHg, an ICP of 20. Calculate the CPP.
70
(MAP-ICP)
A patient has a seizure triggered by flickering lights. This is an example of?
Decreased Seizure Threshold
Co2 level to maintain vasoconstriction?
30-35
How do you calculate MAP?
Diastolic x 2 + Systolic / 3
120/80 = 80x2 + 120 / 3
160 + 120 = 280 / 3 = 93.3333
A nurse is caring for a child with febrile seizures lasting 10 minutes. Which action is most important?
- Administer antipyretic and monitor
- Apply a cooling blanket immediately
- Prepare for IV benzodiazepine admin
- Start chest compressions
Prepare for IV benzodiazepine admin
What ICP level is considered a life-threatening emergency?
an ICP of 40 or higher
The nurse is caring for a patient with suspected herniation. Which sign is most concerning?
- Positive Babinsky
- Decorticate Posturing
- Fixed, dilated pupils
- Headache and Nausea
Fixed, dilated pupils (indicates brain stem compression and impending herniation)
Which nursing diagnosis is priority for a patient who is actively seizing?
- Risk for injury
- Ineffective airway clearance
- Risk for infection
- Knowledge deficit
Ineffective airway clearance