NUR 401: Week 6 Increased inter cranial pressure Questions And Answers With Verified Tests

Assessment of client undergoing intracranial surgery ? - frequent and careful monitoring of Respiratory function ( including ABG's) Monitoring vitals and LOC frequently ( Noting signs of increased ICP) Assess dressing for evidence of bleeding or CSF drainage. Monitor for potential Seizure. record and report them. Monitor signs and symptoms of complications Monitor Fluid status and laboratory data. Compensatory mechanisms for increased ICP ? - 1. Altering CSF Production 2. Displacing CSF into the spinal subarachnoid space, or basal subarachnoid cisterns Earliest sign for increasing ICP ? - Change in LOC, slowing of speech and delay in response to verbal suggestions. Early manifestations of increase ICP ? - Change in level of awareness leading to changes in Level of consciousness. Restlessness confusion increased drowsinessincreased respiratory effort purposeless movements Pupillary changes and impaired ocular movements weakness in one extremity or one side Headache: Constant, increase in intensity or aggravated by moving or straining Enhancing clients self image ? - Encourage verbalization encourage social interaction and support pay attention to grooming cover head with turban and later a wig How does Mannitol help decreased ICP? - Increases serum osmolarity and draws free water from areas of brain How to deal with sensory Deprivation ? - Vision may be impaired: Announce your presence to avoid startling patient. Cool compress over eyes Elevation of HOB to reduce Edema if not contraindicated How to improve gas exchange ? - Turn and reposition patient every 2 hoursEncourage deep breathing and incentive spirometry Suction or encourage coughing cautiously as needed. be careful as this may increased ICP Humidify oxygen to help loosen secretions How to Maintain Cerebral Perfusion ? - Monitor Respiratory status. A slight hypoxia or Hypercapnia can affect cerebral perfusion Assess Vitals and Neurological status every 15 minutes to 1 hour Implement strategies to reduce cerebral edema. Cerebral edema peaks in 24-36 hours Implement strategies to control farces increasing ICP Avoid Extreme head rotation HOB may be flat or elevated ( 30 degrees) according to needs related to surgeon. How to regulate temperature? - Cover patient appropriately treat high temperature elevations vigorously apply iceboats use hypothermia blanket administer prescribed acetaminophenIncreased ICP causes ? What is normal ICP ? - Decreased tissue perfusion, causing ischemia, cell death and Edema. 0-15 mmHg Intracranial pressure monitoring uses a device placed where? what are the three ways to monitor pressure in the skill ? - Inside of the head. Intra-ventricular catheter = most accurate. inserted into the brain through the Lateral ventricle where it monitors ICP and can also drain it out. may be hard to get into place when ICP is high. Subdural screw = used for measurements needed right away. Hole is drilled into the skull and a hollow screw placed through the Dura mater to allow measuring of subdural space. Epidural Sensor = sensor inserted between skull and Dural tissue. placed through a hole in the skull. Least invasive procedure, but cannot remove excess CSF