Increased Intracranial Pressure Care Flashcards

Questions and Answers

What does the nurse concur from the positive Dextrostix test in a patient with clear nasal discharge after head trauma?

The patient has glaucoma.

The patient has sinusitis.

The patient has allergic rhinitis.

The patient has cerebrospinal fluid (CSF) rhinorrhea. (correct)

For which potential complication should the nurse evaluate a patient with a head injury?

Anxiety

Hyperthermia

Impaired physical mobility

Increased intracranial pressure (correct)

Why will the nurse question an order for a benzodiazepine prescribed for a patient with increased intracranial pressure?

It increases anxiety levels.

It may cause sedation.

It may increase the pain.

It causes a hypotensive effect. (correct)

Which symptoms would the nurse expect to find in a patient with a brain abscess in the occipital lobe? (Select all that apply)

Visual impairment and hallucinations Signup and view all the answers

Which statements made by the caregiver indicate the need for further teaching after a patient with a head injury is discharged? (Select all that apply)

"I should maintain a calm environment if the patient is angry." Signup and view all the answers

Which condition indicates to the nurse to maintain closure of the patient's eyes after a traumatic brain injury?

Loss of the corneal reflex Signup and view all the answers

What actions should the nurse plan to perform to provide the most comfort for the patient with increased intracranial pressure (ICP)? (Select all that apply)

Minimize procedures that can produce agitation Signup and view all the answers

What is the patient's cerebral perfusion pressure (CPP) if blood pressure is 162/58 mm Hg and ICP is 35 mm Hg?

58 Signup and view all the answers

Which patient does the nurse suspect may have a lesion in the medulla of brain?

A patient with cluster breathing Signup and view all the answers

Which possible responses could be scored under best motor response on the Glasgow Coma Scale (GCS)? (Select all that apply)

Flexion withdrawal Signup and view all the answers

Which causes of fixed pupils should the nurse consider during assessment? (Select all that apply)

Direct injury to the third cranial nerve (CN III) Signup and view all the answers

What outcome does the nurse anticipate after administering high doses of barbiturates for increased ICP?

Decreases cerebral metabolism Signup and view all the answers

What components are involved in maintaining normal intracranial pressure (ICP)?

Blood pressure, brain tissue, and cerebrospinal fluid Signup and view all the answers

Which actions should the nurse perform to promote optimal outcomes for a patient with increased ICP? (Select all that apply)

Maintain intubation and mechanical ventilation Signup and view all the answers

How can the findings of flexion of the arms, wrists, and fingers in a comatose head-injured patient be described?

Decorticate posturing Signup and view all the answers

Which factors should the nurse consider when administering pharmacologic therapy for a patient with increased ICP? (Select all that apply)

Monitor for hypotension when using continuous intravenous sedatives Signup and view all the answers

What actions should the nurse perform to avoid complications during corticosteroid treatment for increased ICP? (Select all that apply)

Start concurrent treatment with antacids or proton pump inhibitors Signup and view all the answers

What finding indicates deterioration in the condition of a patient with a closed head injury?

Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute Signup and view all the answers

How must cerebral perfusion pressure (CPP) be maintained during suctioning to preserve cerebral perfusion?

Above 60 mm Hg Signup and view all the answers

What is the priority nursing intervention when caring for a patient with increased ICP?

Continuous ICP monitoring Signup and view all the answers

What outcome does the nurse expect after administering mannitol for increased ICP?

Reduced intracranial pressure Signup and view all the answers

What does a CPP of 56 mm Hg indicate for a patient with elevated intracranial pressure (ICP)?

Impaired blood flow to the brain Signup and view all the answers

Which findings would indicate shunt malfunction related to increased ICP? (Select all that apply)

Blurred vision Signup and view all the answers

Which cranial nerve's functioning is evaluated through pupillary response in a patient with head trauma?

III Signup and view all the answers

What behavior after assessing the oculocephalic reflex indicates an intracranial lesion?

Movement of the eye in the sideward direction when the neck is extended Signup and view all the answers

What is the initial action a nurse should take for a patient with head trauma who has a urine output of 300 mL/hr and dry skin?

Evaluate the urine specific gravity Signup and view all the answers

Which indicator is the most reliable for assessing a patient's neurologic status following a head injury?

Level of consciousness Signup and view all the answers

When assessing surgery outcomes in a patient with a brain tumor, which factors should be considered? (Select all that apply)

Surgery can provide relief of symptoms Signup and view all the answers

Which symptoms should a nurse instruct a patient with a head injury to report immediately? (Select all that apply)

Increased drowsiness Signup and view all the answers

What must the nurse include in long-term care planning for a patient following craniotomy?

There are often residual changes in personality and cognition Signup and view all the answers

Which patient assignment is appropriate for a nurse reassigned to a neurologic intermediate care unit?

An alert patient with viral encephalitis who has a scheduled dose of IV acyclovir Signup and view all the answers

In a patient with cerebral edema, what finding is likely if they report a headache and disturbed consciousness?

Increase in extracellular fluid volume Signup and view all the answers

What will be the Glasgow Coma Scale score for a patient with a moderate head injury?

10 Signup and view all the answers

What type of brain herniation is indicated by lateral displacement of brain tissue beneath the falx cerebri?

Cingulate herniation Signup and view all the answers

What is the surgical procedure for redirecting cerebrospinal fluid (CSF) in a patient preparing for cranial surgery?

Shunt placement Signup and view all the answers

Which type of brain tumor is associated with a patient with AIDS who reports uncontrolled urination and excessive thirst?

Primary central nervous system lymphoma Signup and view all the answers

Which aspect of a patient with intracranial pressure (ICP) monitoring requires follow-up by the nurse?

Intracranial device monitoring for greater than 5 days Signup and view all the answers

Which complications can result from brain tumors? (Select all that apply)

Vision loss Signup and view all the answers

Which tumor growth is most commonly associated with acquired immunodeficiency syndrome (AIDS)?

Primary central nervous system lymphoma Signup and view all the answers

What are primary goals when planning care for a patient with a brain tumor? (Select all that apply)

Removing tumor mass Signup and view all the answers

Before administering temozolomide, which factors should the nurse evaluate? (Select all that apply)

Temozolomide can cross the blood-brain barrier Signup and view all the answers

What diagnostic test helps localize a brain tumor and detect blood flow?

Angiography Signup and view all the answers

Which statement made by a newly licensed nurse caring for a patient with a ventricular shunt requires immediate intervention?

I need to tell the UAP to get the patient up quickly to prevent headaches Signup and view all the answers

What surgical procedure does a patient with hydrocephalus prepare for?

Placement of a ventriculoatrial shunt Signup and view all the answers

A patient with a brain tumor presents symptoms of visual disturbances and seizures. Which area of the brain is this tumor most likely located in?

Occipital lobe Signup and view all the answers

Study Notes

Increased Intracranial Pressure (ICP) Overview

ICP management is critical for patient comfort; minimize agitation by avoiding stimulating procedures.
Maintain a quiet environment and closely monitor for agitation signs.
Offer family guidance on limiting stimulation and visit frequency.

Cerebral Perfusion Pressure (CPP)

CPP is calculated by subtracting ICP from the mean arterial pressure (MAP).
MAP formula: (systolic + 2 × diastolic) / 3.
Normal CPP is above 60 mm Hg; lower CPP indicates impaired blood flow to the brain.

Breathing Patterns and Brain Lesions

Cluster breathing suggests a possible lesion in the medulla.
Different breathing patterns correlate with specific brain abnormalities:
- Apneustic breathing indicates mid or lower pons lesions.
- Cheyne-Stokes is associated with bilateral hemispheric disease.
- Central neurogenic hyperventilation is linked to disruptions in the brainstem.

Glasgow Coma Scale (GCS) Best Motor Response

Valid responses under best motor response include:
- Flexion withdrawal
- Localization of pain
- Obedience to command
Eye-opening and disorganized speech are not categorized under motor response.

Fixed Pupils and Their Causes

Fixed pupils unresponsive to light may result from:
- Previous eye surgery
- Increased ICP
- Direct injury to cranial nerve III (CN III)
Administration of diuretics and raised intraocular pressure do not typically cause fixed pupils.

Pharmacologic Management of ICP

High-dose barbiturates decrease cerebral metabolism, aiding in ICP reduction.
Mannitol acts as an osmotic diuretic that effectively reduces ICP by increasing urine output.
Use of sedatives or analgesics alongside neuromuscular blockers is crucial for pain management during procedures.

Monitoring and Interventions

Continuous ICP monitoring is essential for patients with ICP.
Maintain fluid balance and assess osmolality.
Elevate head of the bed to 30 degrees; avoid supine position.

Signs of ICP Deterioration

Late signs of ICP include widening pulse pressure, bradycardia, and decreased respirations.
Blood pressure and heart rate changes are key indicators of neurological deterioration.

Shunt Malfunction Symptoms

Indications of a shunt malfunction may include:
- Blurred vision
- Headaches and vomiting
- Decreased level of consciousness

Assessment of Neurologic Function

Test pupillary response to assess cranial nerve III function; relevant for detecting ICP impact.
Oculocephalic reflex used to identify intracranial lesions; incorrect eye movement suggests a lesion.

High urine output and dry mucous membranes indicate possible diabetes insipidus post-head trauma.
Evaluation of urine specific gravity is a priority to assess hydration status.

General Nursing Considerations

Compare current vital signs with baseline to detect changes associated with ICP.
Monitor patients following head injuries for any deviations in normal neurological responses.
Anticipate potential complications and prepare for necessary interventions.### Neurological Assessments and Conditions
Level of Consciousness: Key indicator of neurologic status; changes may indicate increased intracranial pressure (ICP).
Dim Vision: Can result from cranial nerve dysfunction; important to monitor in neuro patients.
Papilledema: Swelling of the optic disc due to increased ICP; observed during retinal examination.
Body Temperature: Changes may occur due to ICP's effects on the hypothalamus.

Post-Surgical Considerations in Brain Tumor Patients

Surgery can reduce tumor mass, relieve symptoms, and extend survival time but does not usually provide a complete cure.
Post-operative assessment should focus on symptom relief and monitoring ICP.

Head Injury Patient Education

Caregivers should be alerted to report seizures, stiff neck, and increased drowsiness immediately.
Symptoms like sneezing and constipation are typically less concerning and may have alternative explanations.

Long-Term Care After Craniotomy

Expect emotional and cognitive changes; education on these is critical for family coping strategies.
Patients may develop seizures weeks to months post-surgery.

Appropriate Nursing Assignments

A nurse from a medical-surgical unit should monitor an alert patient with viral encephalitis rather than critical post-operative patients or unconscious ones.

Vasogenic Edema: Characterized by increased extracellular fluid volume, typically linked to permeability issues of the blood-brain barrier.
Hypoxia indicates cytotoxic edema, distinct from hydrocephalus caused by interstitial edema.

Glasgow Coma Scale (GCS)

A score of 10 indicates moderate head injury; GCS range for moderate injuries is 9-12.

Types of Herniation

Cingulate Herniation: Occurs with lateral brain displacement beneath the falx cerebri.

Surgical Procedures for CSF Management

Shunt placement is the typical procedure for redirecting cerebrospinal fluid when absorption is impaired.

Brain Tumor Symptoms Associated with AIDS

Primary Central Nervous System Lymphoma: Linked with AIDS; may cause diabetes insipidus symptoms like excessive thirst and urination.

Goals in Brain Tumor Management

Primary goals include tumor mass reduction, identifying tumor type and location, and managing ICP effectively.

Temozolomide Medication Considerations

Evaluate for myelosuppression; the drug effectively crosses the blood-brain barrier and directly affects tumor growth.

Diagnostic Tests for Tumor Localization

Angiography: Used to help localize brain tumors and assess blood flow; not to be confused with EEG or lumbar punctures.

Ventricular Shunt Care

Gradual positioning is crucial to avoid rapid ICP changes; infection prevention measures should be strictly adhered to.

Hydrocephalus Surgical Interventions

Ventriculoatrial Shunt Placement: Effective for draining excess cerebrospinal fluid related to hydrocephalus.

Symptoms of Occipital Lobe Tumors

Common symptoms include visual disturbances, headaches, and seizures.

CSF Rhinorrhea

A positive Dextrostix test indicates cerebrospinal fluid is leaking, a critical finding in head injury assessments.

Monitor for increased intracranial pressure as a significant complication following cerebral hemorrhage and edema.

Benzodiazepine Use in ICP Patients

Caution against benzodiazepines due to potential hypotensive effects that can worsen ICP management.

Symptoms Associated with Brain Abscesses

Headaches, fever, nausea, and potential visual impairment are typical in cases of an occipital lobe abscess.

Caregiver Education After Head Injury

Caregivers must understand when to report symptoms indicating mental status deterioration and avoid practices that may exacerbate swelling.

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Description

This quiz focuses on nursing care strategies for patients experiencing increased intracranial pressure (ICP). It covers key actions nurses should take to ensure patient comfort and minimize agitation. Test your knowledge on the best practices in managing ICP effectively.