40 Questions
What is the primary reason for monitoring intracranial pressure (ICP)?
To detect fluid accumulation or lesions in the cranial cavity
What is the goal of administering Acetaminophen to a patient with elevated temperature?
To lower body temperature
Why is it essential to maintain a normal day-night pattern of activity?
To maintain the patient's natural sleep-wake cycle
What is the purpose of using stool softeners and glycerin suppositories?
To promote bowel function and prevent constipation
Why is it crucial to monitor bowel movements in patients?
To detect potential constipation and abdominal distention
What may result from infection, medications, or hyperosmolar fluids?
Diarrhea
What is the purpose of using a hypothermia blanket?
To reduce body temperature
Why is it essential to orient the patient frequently?
To reduce confusion and disorientation
What is the normal range of Intracranial Pressure (ICP) in mm Hg?
10 to 20
According to the Monro-Kellie Hypothesis, an increase in one of the components of the skull will cause a change in the volume of the others. Which component is normally shifted or displaced to compensate for the change?
Cerebrospinal fluid (CSF)
What is the result of decreased cerebral perfusion due to increased ICP?
Ischemia and cell death
What is the formula for calculating Cerebral Perfusion Pressure (CPP)?
CPP = MAP - ICP
What is the consequence of a CPP of less than 50?
Permanent neurologic damage
What is a common cause of increased ICP?
All of the above
What is a common manifestation of increased ICP?
All of the above
What is the result of increased ICP from any cause?
Decreased cerebral perfusion, edema, and herniation
What is a major goal of nursing care for a patient with increased intracranial pressure?
Normalizing respirations
What is a potential complication of increased intracranial pressure?
Diabetes insipidus
Why is the head of the bed elevated in a patient with increased intracranial pressure?
To promote venous drainage
What is the purpose of monitoring fluid status in a patient with increased intracranial pressure?
To maintain fluid balance
Why is suctioning limited to 15 seconds in a patient with increased intracranial pressure?
To prevent increased intracranial pressure
What is the recommended range for systolic arterial pressure in a patient with increased intracranial pressure?
100 to 160 mmHg
Why is strict aseptic technique used in managing the ICP monitoring system?
To prevent infection
What should be observed during neurologic assessment in a patient with increased intracranial pressure?
Pupillary response to light
What is a characteristic posture in a patient with a severe brain injury at the level of the brainstem?
Decerebrate posturing
What is the primary purpose of diagnostic tests of neurologic dysfunction?
To identify the underlying cause of neurologic dysfunction
What is a common cause of altered level of consciousness?
All of the above
What is a characteristic finding in a patient with an altered level of consciousness?
Unresponsiveness to pain
What is the name of the diagnostic test that uses X-rays to visualization the spinal subarachnoid space?
Myelography
What is the name of the test that measures the electrical activity of the brain?
EEG
What is the term for a state of unconsciousness in which the patient is unaware of their surroundings and is unresponsive to verbal and painful stimuli?
Coma
What is the name of the diagnostic test that uses a lumbar puncture to collect cerebrospinal fluid?
Lumbar puncture
Which part of the nervous system regulates involuntary body functions?
Autonomic Nervous System
What is the primary function of the nervous system?
To control all motor, sensory, autonomic, cognitive, and behavioral activities
What does the decorticate posture indicate in a patient?
Damage to the brain and corticospinal tract
What is the role of the parasympathetic nervous system?
To regulate visceral functions
What is assessed during a neurologic assessment?
Pain, seizures, dizziness, vertigo, visual disturbances, weakness, and abnormal sensations
What is the main neurotransmitter of the sympathetic nervous system?
Norepinephrine
What is the function of the cranial nerves?
To transmit and integrate sensory and motor information
What is the primary function of the spinal cord?
To transmit and integrate sensory and motor information
Study Notes
Normal ICP and Compensation
- Normal ICP is below 15 mm Hg mean pressure
- Compensation to maintain normal ICP (10-20 mm Hg) is accomplished by shifting or displacing CSF
- Monro-Kellie Hypothesis: an increase in any one component of the skull (brain tissue, blood, CSF) will cause a change in the volume of the others
Autoregulation and Cerebral Perfusion Pressure (CPP)
- Autoregulation: brain's ability to change blood vessel diameter to maintain cerebral blood flow
- CO2 plays a role: decreased CO2 results in vasoconstriction, and increased CO2 results in vasodilatation
- CPP (Cerebral Perfusion Pressure) = MAP (Mean Arterial Pressure) - ICP
- Normal CPP is 70-100 mm Hg
Increased Intracranial Pressure (ICP)
- Causes: head injury, tumors, subarachnoid hemorrhage, hematoma, edema, viral encephalopathy
- Effects: decreased cerebral perfusion, edema, and shifts brain tissue through openings in the rigid dura (Herniation)
Manifestations of Increased ICP
- Early changes in Level of Consciousness (LOC)
- Slowing of speech and delay in response to verbal suggestions
- Pupillary changes: diminished response to light, unequal pupil size, dilated pupils, and impaired ocular movements
- Weakness in one extremity or one side
- Headache: constant, increasing in intensity, or aggravated by movement or straining
Nursing Care for Patients with Increased ICP
- Administer IVs, tube feedings, and fluids via feeding tube as required
- Monitor ordered rate of IV fluids carefully
- Maintaining Body Temperature: adjust environment, cover patient appropriately, and use minimum bedding
- Promoting Bowel and Bladder Function: assess for urinary retention and incontinence, and monitor bowel movements
- Sensory Stimulation and Communication: talk to and touch patient, maintain normal day-night pattern of activity, and orient patient frequently
Complications of Increased ICP
- Brain stem herniation
- Diabetes insipidus
- Syndrome of inappropriate antidiuretic hormones (SIADH)
- Infection
Nursing Process: Diagnoses and Planning
- Diagnoses: ineffective airway clearance, ineffective breathing pattern, ineffective cerebral perfusion, deficient fluid volume, risk for infection
- Major goals: maintenance of patent airway, normalization of respirations, adequate cerebral tissue perfusion, fluid balance, absence of infection, and absence of complications
Interventions
- Frequent monitoring of respiratory status and lung sounds
- Maintaining patent airway, suctioning secretions with care, and preventing aspiration
- Intubation and controlled ventilation to PaCo2 of 30-35 mmHg
- Positioning with head in neutral position and elevation of HOB 0-60 degrees to promote venous drainage
- Avoiding hip flexion, extreme rotation of the neck, and flexion of the neck
Anatomy and Physiology of the Nervous System
- Central Nervous System (CNS): brain and spinal cord
- Peripheral Nervous System: cranial nerves, spinal nerves, autonomic and somatic systems
- Autonomic Nervous System: regulates involuntary body functions, maintains and restores internal homeostasis
Neurologic Dysfunction
- Altered Level of Consciousness (LOC): a continuum from normal alertness to coma
- Causes of altered LOC: neurologic, toxicologic, or metabolic
- Diagnosis: unresponsive to voice and pain, dilated or pinpoint pupils, fixed pupils, involuntary movements, and flaccidity or rigidity of muscles
This quiz covers the concept of intracranial pressure, the Monro-Kellie hypothesis, and how the body compensates to maintain a normal ICP. It also discusses the effects of disease or injury on ICP.
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