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What does fixed and dilated pupils at 8 mm indicate?
What is Cushing's triad associated with?
What does a wide pulse pressure indicate?
Which reflex indicates a serious condition when the toes fan out upon stimulation in an adult?
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What does decerebrate posturing indicate?
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What significant change in heart rate is indicative of increased intracranial pressure?
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Which statement is true regarding doll's eyes reflex?
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What is a possible consequence of severe hypertension and bradycardia?
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What are the common late manifestations of deteriorating level of consciousness in severe cases?
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What occurs as pressure on the brainstem increases in a patient experiencing neurological deterioration?
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Which intervention helps to decrease intracranial pressure (ICP) in patients?
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What is a potential benefit of using a subarachnoid screw over other methods to assess ICP?
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What is a common respiratory pattern associated with severe brain dysfunction?
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Which positioning should be avoided to prevent increasing intracranial pressure?
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What is a critical nursing management action for a patient with elevated ICP?
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What does loss of brainstem reflexes indicate in a deteriorating patient?
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What is the patient's heart rate as described in the content?
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What immediate action should be taken for immobilization in this scenario?
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What position is recommended for the patient's head to help lower intracranial pressure (ICP)?
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Why is it important to maintain a low level of carbon dioxide (CO2) in this case?
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What is a key nursing intervention to avoid regarding the patient's extremities?
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The patient's toes fan out when the sole of the foot is stroked. What does this indicate?
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What blood pressure is reported in the patient's observations?
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What should the duration of suctioning be limited to for this patient?
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What is the primary reason for a patient's very low white blood cell count (WBC)?
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Which statement best reflects therapeutic communication with a patient expressing a desire to discontinue treatment due to terminal cancer?
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What major risk is associated with neutropenia in cancer patients?
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Which of the following interventions is most critical for a patient on neutropenic precautions?
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During a chemotherapy cycle, a patient presents with extremely low WBC counts. What should be the nurse's priority focus?
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What key aspect of decision making should be emphasized when discussing care plans with patients who have terminal illnesses?
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What does neutropenic precautions include for patients receiving chemotherapy?
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What is an expected outcome when implementing neutropenic precautions for a patient?
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What is the primary purpose of Mannitol in treating a stroke?
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Which statement about the GCS score is correct?
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When documenting a patient's responses with a GCS score of 11, how should the nurse describe the patient’s orientation?
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What is a common side effect associated with the use of Phenobarbital?
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What does a GCS score of 3 indicate?
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Which type of stroke is classified as a Transient Ischemic Attack (TIA)?
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Which medication is often used to prevent seizures in stroke patients?
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What is the best documentation approach for reporting a decreasing GCS score?
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Study Notes
Increased Intracranial Pressure
- Late manifestations of increased ICP include:
- Decreasing level of consciousness (LOC) until coma
- Irregular respiratory rate and pattern
- Increased blood pressure and temperature
- Widened pulse pressure with rapid fluctuations in heart rate
- Projectile vomiting
- Hemiplegia, decorticate or decerebrate posturing
- Loss of brainstem reflexes (pupillary, corneal, gag, and swallowing)
Surgical Interventions
- Ventriculostomy
- Placement of needle into a lateral ventricle
- Connected to a transducer to monitor ICP
- Drains CSF to reduce pressure
- Can also drain blood from the ventricle
- Subarachnoid Screw
- Hollow screw inserted through the skull and dura mater into the subarachnoid space
- Attached to a pressure transducer
- Avoids complications from a brain shift due to smaller size
Nursing Management
- Patients are located on the critical care unit
- Elevate the head of the bed (HOB) for optimal perfusion pressure
- Provide oxygen therapy to prevent hypoxia
- Maintain the head in a midline, neutral position to promote venous drainage
- Avoid sudden neck or hip flexion which can increase intrathoracic pressure and worsen ICP
Nursing Interventions for Increased ICP
-
Immobilize the head
- Use a cervical collar
-
Control hypercapnia
- Maintain a low PaCO2, as elevated CO2 increases cerebral blood flow and ICP
- Ensure adequate ventilation
-
Positioning
- HOB 30-35 degrees or higher
- Head in neutral position
- Logroll the patient as one unit
-
Suctioning
- Use only when necessary and for short intervals (less than 10 seconds)
- Administer 100% oxygen before and after suctioning.
Glasgow Coma Scale (GCS)
- Highest score: 15
- Lowest score: 3
- A decreasing GCS score indicates worsening neurological function
Treatment: Pharmacology
- Phenytoin - to prevent seizures
- Steroids (dexamethasone) - reduce inflammation
- Phenobarbital - barbiturate that decreases brain activity
- Mannitol - osmotic diuretic to reduce cerebral edema
Neutropenic Precautions
- Neutropenia is a very low white blood cell count, typically when it is below 5,000 cells/mm3.
- Neutropenic precautions are implemented in patients with cancer undergoing chemotherapy and radiation therapy.
- The goal of precautions is to reduce the risk of serious infections.
- Neutropenic precautions frequently include:
- Strict hand hygiene.
- Avoidance of crowds and sick individuals.
- Mouth care and oral hygiene.
- Temperature monitoring.
Cushing's Triad
- Cushing's Triad is a late sign of increased intracranial pressure.
- The triad includes:
- Hypertension (increased systolic blood pressure)
- Bradycardia (slowed heart rate)
- Decreased respirations (irregular or slow breathing pattern)
Stroke (Cerebral Vascular Accident: CVA)
- A stroke is characterized by brain damage due to interrupted blood flow, resulting in oxygen deprivation to the brain.
- There are different types of strokes, including:
- Ischemic stroke: caused by a blockage in an artery supplying blood to the brain
- Hemorrhagic stroke: caused by a rupture of a blood vessel in the brain
- Transient Ischemic Attack (TIA) is a brief interruption of blood flow to the brain, resulting in temporary neurological symptoms.
- Early recognition and treatment are crucial for stroke management.
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Description
This quiz covers the critical aspects of increased intracranial pressure (ICP), including late manifestations and essential surgical interventions like ventriculostomy and subarachnoid screw placement. It also addresses nursing management protocols for patients in critical care units. Test your knowledge on this crucial topic in neurology and nursing.
