NCLEX practice question ICP

A nurse is caring for a pt with Increased intracranial pressure. What trend in the following vital signs would indicate the ICP is rising?
1. Increasing temp, increasing pulse, increasing respirations, decreasing blood pressure.
2.Increasing temp, decreasing pulse, decreasing resps, increasing bp
3.decreasing temp, decreasing pulse, increasing resps, decreasing bp
4.decreasing temp, increasing pulse, decreasing resps, increasing bp

ICP positioning

What is the proper way to position the pt to reduce the ICP?
To promote the venous drainage…head neutral..cervical collar, keep the head of the bed up.
Compression of the jugular vein increases the ICP so…avoid rotation and flexion.
Avoid hip flexion to avoid…intrabdominal pressure which raises the intrathoracic pressure which increases the ICP.
Use turning sheets and pt should exhale when turning..
Colace and NO enemas
Space the care…ICP should not rise above 25mmHg and should return to baseline in 5 min.
Shhhh……..
NO isometric muscle contractions because this will raise the systemic BP and again therefore raise the ICP

ICP to start

• 
  ICP
  Skull volume= brain tissue + blood + CSF.
  MONROE-KELLIE HYPOTHESIS
  There is a limited space inside the skull for expansion and an increase in any of the components will lead to a change in the volume of the other components.
  TO COMPENSATE
  There will be an increased absorption of the CSF and a decreased cerebral blood volume.
  UNCOMPENSATED
  The ICP will rise leading to decreased cerebral perfusion which will lead to edema. Then the brain tissue will shift through openings in the rigid dura leading to herniation and death.
  Remember that an increased ICP leads to decreased cerebral blood flow…leading to ischemia and cell death.
  The systemic response---vasomotor centers are stimulated which increase the BP
  ***Slow bounding pulse and irregular respirations***
  How the body deals with cerebral edema…..The goal is to maintain blood flow and prevent tissue damage. 2 ways the body deals= Auto regulation of blood vessel diameter, and decreasing production of the CSF.
  CUSHINGS TRIAD
  Bradycardia
  Hypertension
  Bradypnea
  Seen with pressure on the medulla from brain stem herniation.
• Pathological Conditions that can cause ICP
  Head injury, CVA, brain tumor, intracranial Sx, meningitis, encephalitis, subarachnoid hemorrhage.
• Early symptoms of ICP= a change in the LOC= slow speech, delayed responses, irritable, restless and increased effort of resps. Change in pupils, weakness on one side, headache that increases.
• Late symptoms of ICP= Worsening LOC leading to coma. Sluggish pupil response, decreased HR, decreased RR. Bradycardia to tachycardia. BP and temp will rise. The pulse pressure widens, Cheyne stokes resps, PROJECTILE VOMITING, hemiplegia, decorticate or decerebrate posture, flaccid before death. Loss of brain stem function. Increased systolic pressure.
  ASSESS
  LOC, pupil response, VS, motor activity
  VS=pulse decreases, resps decrease, BP increases, Temp increases.
  Diagnostics= CT scan, MRI, PET
  MANAGEMENT
  Goal is to relieve the ICP by decreasing edema, decrease volume of CSF, decrease cerebral blood volume while still maintaining adequate perfusion.
  Monitoring the ICP
  Intraventricular catheter= ventriculostomy.into lateral ventricle. Allows for drainage. Meds can be instilled. Risks are infection and ventricle collapse.
  Subarachnoid bolt=or screw…hollow device through the skull and dura mater into the cranial subarachnoid space. No ventricle puncture. Negative aspect = blockage leading to decreased accuracy of reading.
  Epidural/subdural catheter= non electrical basis. Low incidence of infection. Can not withdrawal CSF for analysis.
  ***Remember the ventricles are the storage tanks for CSF***
  To decrease the cerebral edema
  Mannitol=and osmotic diuretic to dehydrate the brain tissue. This works by drawing the water across intact membranes. Need strict I&O
  Corticosteroids--dexamethasone is given to reduce the edema
  Fluid restrictions--- to lead to dehydration and hem concentration which is again drawing fluid across the osmotic gradient which will decrease the edema.
  Maintain the cerebral perfusion
  Manipulate cardiac output to provide enough perfusion to the brain. Improve Cardiac output. This is done by fluid volume and inotropic agents= dobutamine hydrochloride. This is checked by monitoring the cerebral perfusion pressure and it should be maintained at 70mmHg or greater.
  Reduce the CSF and intracranial blood volume with drains…but be careful of over drainage can lead to collapse. Hyperventilation of patients is only used for patients that do not respond to the other therapies.
  Control the fever….shivering increases ICP…fever increases cerebral metabolism and edema.
  Reduce metabolic demands
  Barbiturates= Nembutal, pentothal, diprivan. When administering paralyzing agents…..require intubation, arterial pressure monitoring…ICP monitoring.
  ASSESSMENTS based on location in the brain
  ICP on the frontal lobes will lead to Cheyne stokes resps
  ICP in midbrain will lead to hyperventilation
  ICP in stem (pons, medulla) leads to irregular resps and apnea.
  INTERVENTIONS
  Elevate the head of the bead 30-40 degrees as prescribed.
  Avoid Trendelenburg’s position
  Prevent flexion of neck and hips
  Monitor resp status and hypoxia
  Avoid morphine sulfate
  Maintain PaCO2 at 30-35mmHg. This will result in vasoconstriction of the cerebral blood flow vessels, decreased blood flow and a decreased ICP.
  Maintain body temp--anti pyretics ,
  Prevent shivering.
  Decrease environmental stimuli
  Monitor lyte and fluid balance
  I&O
  Limit fluid intake 1200mL/day--decrease edema
  Avoid straining, coughing sneezing
  Avoid valsalva maneuver.
  Seizure precautions--pad rails, have O2 and suction.
• Avoid straining, coughing sneezing
  Avoid valsalva maneuver.
  Seizure precautions--pad rails, have O2 and suction.