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ICP

QuestionAnswer
unresponsiveness to the environment; the patient makes no movement or sound but sometimes opens the eyes akinetic mutism
condition resulting from a lesion in the pons in which the patient lacks all distal motor activity (paralysis) but cognition is intact locked-in syndrome
an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities decortication
an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities; usually indicates more severe damage decerebration
theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents—brain tissue, blood, or cerebrospinal fluid (CSF)—causes a change in the volume of the others Monro–Kellie hypothesis (also referred to as Monro–Kellie doctrine)
with disease or injury, what may increase? an increase in this can cause ischemia, cell death, and (further) edema ICP
normal ICP level? compensation to maintain this normal level is normally accomplished by shifting or displacing CSF 10 to 20
refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow autoregulation
increased ICP: CO2 plays a role; decreased CO2 results in _____, and increased CO2 results in _____ vasoconstriction, vasodilatation
T or F? The earliest sign of increasing ICP is a change in LOC. True (The earliest sign of increasing ICP is a change in LOC. Slowing of speech and delay in response to verbal suggestions are other early indicators.)
cerebral perfusion pressure (CPP) calculation? normal CCP? *CPP = MAP (systolic BP + 2(diastolic BP)/3) – ICP *normal CCP is 70 to 100
a CCP of less than __ results in permanent neurologic damage 50
calculate CCP: ICP = 10 mmHg BP = 120/80mmHg MAP = (systolic BP + 2(diastolic BP))/3 MAP = (120 + 2(80))/3 = 93 CPP = 93-10 = 83mmHg CPP WNL
what happens if ICP rises to level of MAP? no brain perfusion → brain death
S/Sx: -changes in LOC -restlessness, confusion, ↑ drowsiness, ↑ resp effort, purposeless movements -pupillary changes & impaired ocular movements -weakness in one extremity or one side -HA: constant, ↑ in intensity or aggravated by movement/straining early S/Sx of ↑ ICP
S/Sx: -↑ SBP, temp ↑ -Cushing’s triad: bradycardia, HTN, bradypnea -projectile vomiting -stupor to coma -hemiplegia, decortication, decerebration, or flaccidity -resp alterations (Cheyne-Stokes and arrest) -loss of brainstem reflexes late S/Sx of ↑ ICP
occulomotor reaction: eyes move opposite direction of head rotation (normal response); must be cleared if cervical injury; result determines intact brainstem oculocephalic (doll's eyes)
occulomotor reaction: irrigate ear canal with ice water - eyes deviate to ear irrigated (normal response); contraindicated if CSF or purulent drainage leaking from ear, or tear in tympanic membrane; result determines intact brainstem oculovestibular (cold calorics)
opening of the skull; purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, control hemorrhage craniotomy
excision of portion of skull craniectomy
repair of cranial defect using a plastic or metal plate cranioplasty
circular openings for exploration or diagnosis to provide access to ventricles or for shunting procedures, aspirate a hematoma or abscess, or make a bone flap Burr holes
What is the purpose of burr holes in neurosurgical procedures? -Make a bone flap in the skull -Aspirate a brain abscess -Evacuate a hematoma -All of the above All of the above (The purpose of burr holes in neurosurgical procedures is to make a bone flap in the skull, aspirate a brain abscess, and evacuate a hematoma.)
What sign or symptom is not an indication of CSF leakage? -Patient complains of a salty taste in the mouth -Patient complains of postnasal drip -Clear fluid draining from nose -Altered LOC Altered LOC (S/Sx of CSF leakage that nurse should investigate further would include: pt c/o salty taste in mouth, postnasal drip, or if clear fluid draining from nose or incision. Altered LOC is a sign of ↑ ICP but not a sign or symptom of CSF leakage.)
abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons seizures
type of seizure? begin in one part of the brain; simple (consciousness remains intact) or complex (impairment of consciousness) partial seizures
type of seizure? involve the whole brain generalized seizures
causes of seizures? -Cerebrovascular disease -Hypoxemia -Fever (childhood) -Head injury -HTN -CNS infections -Metabolic and toxic conditions -Brain tumor -Drug and alcohol withdrawal -Allergies
-primary: no known organic cause and includes migraine, tension, and cluster -secondary: a symptom with an organic cause such as a brain tumor or aneurysm -may cause significant discomfort for the person and can interfere with activities and lifestyle headache (cephalgia)
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to -control fever. -control shivering. -dehydrate the brain and reduce cerebral edema. -reduce cellular metabolic demand. dehydrate the brain and reduce cerebral edema. (Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.)
What is one of the earliest signs of increased ICP? -↓ level of consciousness (LOC) -headache -Cushing's triad -coma ↓ level of consciousness (LOC) (Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.)
CPP? WNL? If not WNL, explain potential problem. B/P is 124/75, ICP is 12. 79, WNL
CPP? WNL? If not WNL, explain potential problem. B/P 120/90, ICP 15. 85, WNL
CPP? WNL? If not WNL, explain potential problem. B/P 90/50, ICP 14. 49, Not WNL, pt not perfusing, loss of autoregulation and oxygen to brain
CPP? WNL? If not WNL, explain potential problem. B/P 170/98, ICP 19. 103, Not WNL, potential risk is ↑ swelling leading to impaired autoregulation and inadequate blood and oxygen supply
CPP? WNL? If not WNL, explain potential problem. B/P 110/70, ICP 8. 75, WNL
Cushing's triad? HTN, bradycardia, bradypnea
Created by: nurse savage
 

 



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