NUR 425 ALL EXAMS 3 QUESTIONS AND
ANSWERS SURE A+
✔✔Cycles of hyperventilation and apnea - ✔✔Cheyne-Stokes
✔✔Sustained regular rapid and deep breathing - ✔✔Central neurogenic
hyperventilation (Kussmaul)
✔✔Completely irregular with some breaths deep and some shallow. Random, irregular
pauses, slow rate. Drunk breathing. - ✔✔Ataxic breathing
✔✔Which response is activated with increased ICP? - ✔✔Sympathetic nervous system
causing ipsilateral (one side) pupillary dilation
✔✔This device drains cerebrospinal fluid to reduce ICP. Trends ICP and drains as
necessary. Not every patient has their CSF drained! - ✔✔External Ventricular Drain
✔✔List some nursing interventions for IICP. - ✔✔-Raise HOB (but not too high) to
facilitate outflow but promote CPP
-Prevent flexion of the neck and all joints below the brain
-Provide skincare
-Prevent infection and/or hemorrhage
-Manage pain, reduce anxiety, and reduce environmental stimuli
-Decrease metabolic demand by reducing stress, avoiding suctioning (Keep <10
seconds at a time) unless indicated, decreasing abdominal distention (Abdominal
distention reduces venous blood return), reduce fever, reduce risk of seizures, and
reduce shivering
-Assess neurological status frequently
-Keep pt. normotensive, hydrated, and nutritionally adequate
-Allow family involvement as appropriate (Monitor ICP/CPP during family involvement)
-Maintain normal ICP, CBF, and CPP
, -Watch for secondary brain injury (Ex. brain herniation from increased ICP from a head
trauma)
-Administer osmotic diuretics (Mannitol or 3% NaCl) or loop diuretics (Lasix) to remove
fluid from the brains extracellular compartment
-Monitor ventilation and oxygenation (Do not hyperventilate!)
-ICP monitoring if GCS 3-8, EVD needed
-Administer anti-seizure drugs (Phenytoin/Dilantin)
-Administer corticosteroids (Dexamethasone) to reduce swelling with tumors and
cerebral edema
-Give breaks between care, monitor ICP during care
✔✔Abnormal flexion: indicative of a cerebral lesion - ✔✔Decorticate
✔✔Abnormal extension: indicative of a brainstem or midbrain lesion. - ✔✔Decerebrate
✔✔Where should the transducer for and EVD be leveled at? - ✔✔Foramen of Monro
(Tragus of ear)
✔✔Should we keep the EVD open or closed during position changes? - ✔✔Closed and
always reassess level of transducer after position change
✔✔How do we make sure we have an accurate ICP signal from an EVD? - ✔✔-The
EVD should be closed for at least 6 minutes before waveform is considered accurate
-Stopcock closed allowing signal from EVD to monitor, don't trust ICP when the CSF is
openly draining!
-Evaluate for causes in inaccurate ICP waveform such as improper level of transducer,
bubbles in the tubing, kinks in the tubing, CSF leaks, and obstructions.
✔✔Why do we give hypertonic solutions (Ex. 3% NaCl) to a patient with an increased
ICP? - ✔✔The hypertonic solution causes fluid to shift from the brain cells to the vessels
so we can get the fluid out of the brain to decrease pressure.
✔✔How quickly should we give 3% NaCl/hypertonic solutions? - ✔✔Very slowly, around
30 mL/hr. We DO NOT flush 3% NaCl. The brain will shrink too quickly. Also MUST be
given through a central line.
✔✔You are caring for a 67 year old female admitted for a fall causing a subarachnoid
hemorrhage. She is confused, reporting a headache at 8/10 and has the following
VS: 165/90, HR 70, O2sats 88%, RR: 10, T: 38.2 C. Her labs include: Na: 119, K: 3.5.
She has an EVD trending an ICP of 20.
Determine all of the factors potentially causing IICP and discuss what you would do for
this patient. - ✔✔-The high blood pressure
-Low oxygen saturation
ANSWERS SURE A+
✔✔Cycles of hyperventilation and apnea - ✔✔Cheyne-Stokes
✔✔Sustained regular rapid and deep breathing - ✔✔Central neurogenic
hyperventilation (Kussmaul)
✔✔Completely irregular with some breaths deep and some shallow. Random, irregular
pauses, slow rate. Drunk breathing. - ✔✔Ataxic breathing
✔✔Which response is activated with increased ICP? - ✔✔Sympathetic nervous system
causing ipsilateral (one side) pupillary dilation
✔✔This device drains cerebrospinal fluid to reduce ICP. Trends ICP and drains as
necessary. Not every patient has their CSF drained! - ✔✔External Ventricular Drain
✔✔List some nursing interventions for IICP. - ✔✔-Raise HOB (but not too high) to
facilitate outflow but promote CPP
-Prevent flexion of the neck and all joints below the brain
-Provide skincare
-Prevent infection and/or hemorrhage
-Manage pain, reduce anxiety, and reduce environmental stimuli
-Decrease metabolic demand by reducing stress, avoiding suctioning (Keep <10
seconds at a time) unless indicated, decreasing abdominal distention (Abdominal
distention reduces venous blood return), reduce fever, reduce risk of seizures, and
reduce shivering
-Assess neurological status frequently
-Keep pt. normotensive, hydrated, and nutritionally adequate
-Allow family involvement as appropriate (Monitor ICP/CPP during family involvement)
-Maintain normal ICP, CBF, and CPP
, -Watch for secondary brain injury (Ex. brain herniation from increased ICP from a head
trauma)
-Administer osmotic diuretics (Mannitol or 3% NaCl) or loop diuretics (Lasix) to remove
fluid from the brains extracellular compartment
-Monitor ventilation and oxygenation (Do not hyperventilate!)
-ICP monitoring if GCS 3-8, EVD needed
-Administer anti-seizure drugs (Phenytoin/Dilantin)
-Administer corticosteroids (Dexamethasone) to reduce swelling with tumors and
cerebral edema
-Give breaks between care, monitor ICP during care
✔✔Abnormal flexion: indicative of a cerebral lesion - ✔✔Decorticate
✔✔Abnormal extension: indicative of a brainstem or midbrain lesion. - ✔✔Decerebrate
✔✔Where should the transducer for and EVD be leveled at? - ✔✔Foramen of Monro
(Tragus of ear)
✔✔Should we keep the EVD open or closed during position changes? - ✔✔Closed and
always reassess level of transducer after position change
✔✔How do we make sure we have an accurate ICP signal from an EVD? - ✔✔-The
EVD should be closed for at least 6 minutes before waveform is considered accurate
-Stopcock closed allowing signal from EVD to monitor, don't trust ICP when the CSF is
openly draining!
-Evaluate for causes in inaccurate ICP waveform such as improper level of transducer,
bubbles in the tubing, kinks in the tubing, CSF leaks, and obstructions.
✔✔Why do we give hypertonic solutions (Ex. 3% NaCl) to a patient with an increased
ICP? - ✔✔The hypertonic solution causes fluid to shift from the brain cells to the vessels
so we can get the fluid out of the brain to decrease pressure.
✔✔How quickly should we give 3% NaCl/hypertonic solutions? - ✔✔Very slowly, around
30 mL/hr. We DO NOT flush 3% NaCl. The brain will shrink too quickly. Also MUST be
given through a central line.
✔✔You are caring for a 67 year old female admitted for a fall causing a subarachnoid
hemorrhage. She is confused, reporting a headache at 8/10 and has the following
VS: 165/90, HR 70, O2sats 88%, RR: 10, T: 38.2 C. Her labs include: Na: 119, K: 3.5.
She has an EVD trending an ICP of 20.
Determine all of the factors potentially causing IICP and discuss what you would do for
this patient. - ✔✔-The high blood pressure
-Low oxygen saturation
