Assessment
The normal range of ICP
10-15 mm Hg
A patient with ICP should have the HOB at least _______ degrees unless otherwise indicated.
What is 30
This medication is an osmotic diuretic used to treat cerebral edema.
What is Mannitol
A clear or yellowish ring surrounding a spot off blood
What is "halo" sign
Damage to the brain from an external mechanical force and not caused by neurodegenerative or congenital conditions
TBI Traumatic Brain Injury
These are EARLY signs of increased intracranial pressure? (There are 7 listed, I need at least 3 for points)
What is nausea, headache, vomiting, deteriorating LOC, restless, irritability, dilated or pinpoint fixed pupils
The nurse should avoid extreme flexion, extension, or rotation of the head and maintain the body in ____________ position.
What is midline neutral
You need to administer mannitol through a ________ in the IV tubing to eliminate microscopic crystals.
What is filter
Abnormal posturing seen in the patient with lesions that interput the corticospinal pathways. The arms, wrist, and fingers are flexed with internal rotation and plantar flexion of the legs
What is Decorticate Posturing
Abnormal accumulation of cerebrospinal fluid within the skull causing increased ICP.
What is hydrocephalus
Placing a screw, catheter, or a sensor through a burr hole into the ventricle, subarachnoid, epidural, or subdural space will allow you to monitor________.
What is Intracranial Pressure
The nurse would document a GSC score of what or a patient who has eyes open to command, with abnormal flexion, and is disoriented?
What is 10
Two of the possible side effects of mannitol (there are 6 listed, I need two for points)
What is severe dehydration, F&E Imbalance, acute renal failure, edema, weakness, changes in urine output
Abnormal posturing and rigidity characterized by the extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos; usually associated with dysfunction in the brainstem area.
What is Decerebrate Posturing
This is the term associated with a PaCo2 greater than 45 causes cerebral vasodilation and contributes to increased ICP.
What is hypercarbia
This is a pattern of respirations that involves a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all, called apneas.
What is Cheyne-stokes respirations
This type of fluid should never be given to a patient with increased intracranial pressure.
Hypotonic Solution
These are the two main electrolytes that can become unbalanced when using mannitol.
What is potassium and sodium
A way of helping brain-injured patients regain function in areas that are essential for a return to independence and a reasonable quality of life.
Cognitive Rehabilitation
Preventing this maneuver is important because it can directly cause an increase in ICP.
What is Valsalva/Vagal maneuver
Severe hypertension, widened pulse pressure (increasing difference between systolic and diastolic) and bradycardia are late signs of increased ICP known as
Cushing's Triad
A client on a ventilator has increase paC02 and the physician orders the nurse to increase the respiratory rate, the nurse understands that this will lower the ICP by lowering ___________.
C02
Patients who are receiving mannitol should have one of these placed to monitor strict output hourly.
Indwelling catheter
Edema and hyperemia (increased blood flow) of the optic disc. *This is always a sign of increased ICP)
What is papilledema
______ cause a potential life threating increase in intracranial pressure because they act as space occupying lesions and are surrounded by edema.
What is a hematoma