NUR 405 Unit 2
- Causes of increased ICP
Answer
temperature, arterial & Venous pressure, position, aneurysms, hydrocephalus, head trauma, meningitis, tumors
- what is the earliest sign of increased ICP
Answer
Change in LOC, decreased mental status
- what is cerebral perfusion pressure (CPP)
Answer
pressure needed to ensure blood flow to the brain.
the difference between ICP and MAP
- Early signs of increased ICP
Answer
Altered LOC, irritability, restlessness, decreased mental status, sleepiness, flat affect, drowsiness
- what is the calculation for CPP
Answer 1 / 3
MAP - ICP (Normal 70/80; less than 60 = tissue death)
- what is the calculation for MAP
Answer
SBP+2(DBP)/3
- Moderate signs of increased ICP
Answer
headache, vomiting,
- what are late signs of increased ICP
Answer
Cushing's triad nuchal rigidity
fixed & dilated pupils babinski reflex seizures & coma Decorticate and decerebrate posturing
- Signs of Cushing's triad
Answer
Systolic hypertension bradycardia
irregular respirations
- what medication is given to reduce cerebral edema
Answer 2 / 3
mannitol. - osmotic diuretic
- Key points for Mannitol
Answer
- IV admin
-causes peripheral edema -increased UO and can affect electrolytes
- Nursing interventions for increased ICP
Answer
-Hourly VS and neuro checks
-HOB @ 30 degrees -Do not cluster care -Decrease stimuli -Temperature control -Hyperoxygenate -Don't suction often -No valsalva
- Eye Opening Response scoring on GCS
Answer
- - spontaneously 3- to speech
- - to pain
- - no response
- / 3