The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following?

Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

The client’s serum osmolality is 310 osm/L

A client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following findings indicates that the medication is having a therapeutic effect?

Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately.

 A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure?

 It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP)

Remove extra blankets and give the patient a cool bath

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these finding

 These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following:

The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

Which is the earliest sign of increasing intracranial pressure?

Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

se of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Avoiding flexion of the neck with use of a cervical collar

Rotating the neck to the far right with neck support

Extreme hip flexion, with the hip supported by pillows

Keeping the head flat, avoiding the use of a pillow

Which positions are used to help reduce intracranial pressure (ICP)?

Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP

Which is a late sign of increased intracranial pressure (ICP)?

*Coughing, sneezing, talking, and valsalva manuver can increase intracranial pressure

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? SATA

Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

Monitor fluid and electrolyte status carefully.

Administer vasoconstrictors to maintain cerebral perfusion.

Position the patient in a high Fowler's position

Maintain physical restraints to prevent episodes of agitation.

What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP?

*Maslow's hierarchy of needs (airway, breathing, and circulation)---hypoxia can increase ICP 

neurologic status with Glascow Coma Scale

 A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?

*Hip and neck flexion stops drainage. Elevate the HOB at least 30-45 degrees to reduce ICP & promote venous drainage

Cluster nursing activities to provide periods of uninterrupted rest

Routinely suction to prevent accumulation of respiratory secretions

Avoid positioning the patient with neck and hip flexion

Maintain hyperventilation to a PaCO2 of 15-20mmHg

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient?

*Decreasing the noise level and restriciting the number of people in the client's room can help prevent increases in ICP, administration of stool softener will decrease need to bear down during bowel mcvements (valsalva maneuver) which can increase ICP

A client has a closed head injury with ICP readings ranging from 16-22 mm hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP SATA

*headache, decorticate posturing, and dilated pupils are all expected findings of increased ICP

A nurse in critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessments are indicative of increased ICP?

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased

Blood pressure 110/70, pulse 76, respirations 40

Blood pressure 130/72, pulse 90, respirations 32

Blood pressure 148/78, pulse 112, respirations 28

Blood pressure 156/60, pulse 55, respirations 12

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to

*Perform exercises ess frequently because posturing can increase ICP

continue the exercises because they are necessary to maintain musculoskelet

use restraints to protect the patient from injury

administer CNS depressants to lightly sedate the patient

perform the exercises less frequently because posturing can increase ICP

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do FIRST?

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?

*Use airway, breathing, circulation priority setting framework. Brain tissue can only survive 3 minutes before permenant damage occurs. 

A nurse is caring for a client who had just been admitted following surgical evacuation of subdural hematoma. Which of the following is a priority assessment?

A client with IICP requires an environment with reduced stimulation to help keep the pressure​ lowered; therefore, encouraging family to keep the client engaged in normal activities can worsen the​ client's condition.

 Encourage family to visit and keep the client engaged in normal activities

Assess​ LOC, pupillary​ response, and neurologic status.

Maintain the head of the bed at 30 degrees.

Implement deep vein thrombosis prophylaxis.

Monitor​ ICP/cerebral perfusion pressure​ (CCP) as indicated.

Which intervention should the nurse initiate secondary to a change in the level of consciousness​ (LOC) for a client experiencing increased intracranial pressure​ (IICP)?  SATA