ICP
What are the the main structures that play a role in altering intracranial pressure?
A: Brain, CSF and Blood
R: Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.
What is the formula to calculate Cerebral Perfusion Pressure?
CPP=MAP-ICP
Pg. 1315
During the assessment of a patient, their eyes open to pain. They were communicating with disorganized speech and when told to raise their arm and hold up two fingers, they flexed the arm at the elbow and made a fist. How would you score this patient on the Glasgow Coma Scale?
2+3+3 = 8
_______ is the respiratory pattern seen in comatose patients that is characterized by cycles of hyperventilation and apnea
A: Cheyne-Stokes
R: Other abnormal respiratory patterns such as central neurogenic hyperventilation, apneustic breathing, cluster breathing, and ataxic breathing are not cyclical
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign or symptom below is the EARLIEST indicator that the patient is experiencing increased ICP?
A. Bradycardia
B. Decerebrate Posturing
C. Disorientation
D. Unequal Pupil size
A: C
R: Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.
Which patient below is at MOST risk for increased intracranial Pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brian injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.
A: B
R: Common causes of increased ICP include a mass (e.g., hematoma, contusion, abscess, tumor) and cerebral edema (associated with brain tumors, hydrocephalus, head injury or brain inflammation) pg. 1316
When cerebrovascular resistance is high, blood flow to brain tissue is ______
A: Impaired / reduced
R: If resistance is increased (active), flow will decrease (passive) Cerebrovascular resistance generated by arterioles within the cranium, links CPP and blood flow as: CPP= flow x resistance
Pg. 1315
The nurse notices their patient who initially came in after hitting their head and came in fully oriented, is now having slurred speech and is confused.What is the primary nursing assessment.
A. Raise head of Bed.
B. Vitals
C. Glasgow Coma Scale
D. Neurological assessment
Answer: B. Vitals to assess for cushing triad due to the patients quick decline
A is not an assessment, C and D not a priority now patient is decreasing
SIADH can result in which of the following complications (select all that apply)
A. increased urine output
B. hypernatremia
C. cerebral edema
D. hyponatremia
A: C, D
R: SIADH is characterized by an increase in ADH secretion - ADH tells the body to retain water and sodium follows. This results in decreased urine output and hyponatremia.
Which Patient below with ICP is experiencing Cushing’s Triad?
A. BP 145/110, HR 80,
RR 10
B. BP 90/50, HR 80,
RR 20
C. BP 110/80, HR 112,
RR 22
D. BP 205/65, HR 55,
RR 8
A: D
R: These vital signs represent Cushing's Triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and irregular respirations bradypnea.
___________is a neurologic emergency that includes systolic HTN, Bradycardia and altered respirations.
A: Cushing’s triad
R: With a loss of autoregulation, the body attempts to maintain cerebral perfusion by increasing systolic BP. However, decompensation is imminent. The patient's response is characterized by systolic HTN with a widening pulse pressure, bradycardia with a full and bounding pulse, and altered respirations. Pg. 1316
What does compliance mean in terms of CPP? What is happening at stage 3 of the intracranial pressure/volume curve?
A/R: Compliance is the expandability of the brain. It is represented as the volume increase for each unit increase in pressure. At stage 3 of the intracranial pressure/ volume curve, compliance is significantly reduced. Any small addition to volume causes great increase in pressure, and compensatory mechanisms fail.
Pg 1315-1316
Which motor and sensory function should the nurse find abnormal (Select all that Apply)
A. Failure to withdraw from painful stimuli
B. Paralysis.
C. Sluggish or no pupillary response to light.
D. Unilateral or bilateral weakness.
ABD, C is not a motor response
P1324
A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to:
A. Keep the head of the bed flat
B. Elevate the head of the bed to 30 degrees
C. Maintain the patient on the left side with the head supported on a pillow.
D. Use a continuous-rotation bed to continuously change patient position
A: B
R:
A. Keeping the head of the bed flat would increase ICP
B. 30 degrees allows the patient’s head to be maintained in a midline position and avoid extreme neck flexion. Raising the bed above 30 degrees could decrease CCP by lowering systemic BP
C. This position does not maintain the head in a midline position
D. The patient must be turned with slow, gentle movements because rapid changes can increase ICP.
During an eye assessment of a patient with increased ICP, you are assessing the oculocephalic reflex. If the patient has brain stem damage what response would you find?
A. The eyes will move in the same direction as the head is moved side to side
B. The eyes will be in a fixed position as the head is moved side to side
C. The eyes will roll back as the head is moved side to side
D. The eyes will move in the opposite direction as the head is moved side to side
A: B
R: This is known as a negative doll’s eye and represents brain stem damage. This is a very bad sign.
List the six factors that influence ICP under normal circumstances?
A:
1-Arterial Pressure
2-Venous Pressure
3-Intraabdominal and intrathoracic pressure
4-Posture
5-Temperature
6- Blood Gases
R: Pg. 1314
What are the three symptoms associated with Cushing’s Triad and when does it occur?
Systolic hypertension with a widening pulse pressure
Bradycardia
Altered Respirations
When assessing an uncooperative patient the nurse brisky turns the patients head while holding their eyelid open. What is the nurse assessing?
A. Corneal Reflex
B. Pain stimulus
C. Oculocephalic reflex
D. Motor Strength
C. Doll's eye reflexThe nurse is looking for the patient's eyes to move across the midline in the opposite direction of which their head is being turned.
P. 1324
A patient who has increased ICP is at a risk for seizures. Which of the following interventions will the nurse institute? (select all that apply):
A. Administer prophylactic antiseizure medication
B. Use a calm voice when talking to the patient
C. Move patient to a room close to the nurse’s station
D. Have suction readily available at the bedside
A: B,D
R: A. the use of prophylactic antiseizure drugs is controversial, as their use may not decrease seizures
B. Patient will benefit from a calm approach and light touch
C. The patient should be placed in a quiet, non-stimulating environment.
D. Suction should be available to clear the airway if needed while the patient is having a seizure
During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out with hyperpronation of the forearms and toes pointed downward. You will document this as:
A. Decorticate Posturing
B. Decerebrate Posturing
C. Flaccid Posturing
D. Opisthotonic Posturing
A: B
R: This describes B; In Decorticate Posturing the arms would be bent towards the body with the wrists and fingers bent and held on the chest. Flaccid posturing is when the muscles do not contract at all and stay weak/ floppy. Opisthotonic Posturing is where the back becomes extremely arched due to muscle spasms.