Increased ICP
What is the normal range for intracranial pressure?
5-15 mmHg
Which patient should the nurse see first: a post-op appendectomy patient reporting pain or a head injury patient with a change in LOC?
The head injury patient with a change in LOC.
What is the most common type of stroke?
Ischemic stroke.
What intervention helps prevent pressure ulcers in immobile stroke patients?
Repositioning every 2 hours.
What is a common early sign of increased ICP?
Headache.
Name one non-pharmacological intervention to reduce ICP.
Elevate the head of the bed to 30 degrees. Maintain normal body temp.
Which intervention takes priority for a patient showing early signs of increased ICP?
Ensuring proper oxygenation and raising the head of the bed.
What is the time window for administering tPA in an ischemic stroke?
Within 3 to 4.5 hours from symptom onset.
Which nursing action can help reduce ICP by decreasing stimuli?
Keeping the room quiet and limiting visitors.
Which symptom is a hallmark of a hemorrhagic stroke?
Sudden, severe headache
What does the Monro-Kellie doctrine state?
The total volume of brain tissue, blood, and CSF within the skull must remain constant.
True or False: You should prioritize treating pain in a patient with ICP over ensuring proper oxygenation.
False. Oxygenation is a priority because hypoxia can exacerbate increased ICP.
What type of stroke involves bleeding into the brain tissue?
Hemorrhagic stroke.
True or False: Hyperventilation can be used temporarily to lower ICP.
True.
Rationale: It helps reduce CO2 and induces cerebral vasoconstriction.
What symptom might indicate a patient is experiencing expressive aphasia?
Inability to speak or form coherent words while understanding speech.
What late sign indicates increased ICP and is part of Cushing’s triad?
Widened pulse pressure, bradycardia, and irregular respirations.
A patient with a stroke is experiencing difficulty swallowing. What is the nurse's priority action?
Place the patient on NPO status until a swallow evaluation can be conducted.
What scale is used to assess the severity of a stroke?
NIH Stroke Scale (NIHSS).
What is the priority action when a stroke patient is showing signs of worsening hemiplegia?
Perform a rapid neurological assessment and notify the physician.
Name a late sign of increased ICP.
Fixed, dilated pupils.
What medication is most commonly used to decrease increased intracranial pressure
Osmotic diuretics- Mannitol
In the case of simultaneous patient calls, who should the nurse assess first: a patient post-CVA with dysphagia or a patient post-brain surgery showing signs of vomiting?
The patient post-brain surgery with vomiting.
Rationale: Vomiting could indicate increased ICP, needing immediate attention.
Name one modifiable risk factor for stroke.
Hypertension, smoking, diabetes
What position should a patient with increased ICP be placed in?
Semi-Fowler's (30 degrees elevation).
Rationale: Promotes venous drainage without compromising cerebral perfusion.
What is Cushing’s triad a sign of?
Increased intracranial pressure.