NCLEX Review & Nursing School

INCREASED INTRACRANIAL PRESSURE

– Increase in pressure within the cranium.

CAUSES:

• Edema
• Trauma
• Hemorrhage
• Normal ICP:  5- 15 mm Hg.

INTERVENTIONS:

• * NO VAGAL STIMULATION W/  PATIENT
• IMPLEMENT SEIZURE PRECAUTIONS
• MAINTAIN PATENT AIRWAY

ASSESSMENT

• EARLIEST SIGN: DECREASE IN LOC, RESTLESSNESS AND CONFUSION
• PROJECTILE VOMITING
• CHANGES IN VITAL SIGNS (MAY BE A LATE SIGN).
• SYSTOLIC BLOOD RISES WHILE DIASTOLIC PRESSURE REMAINS THE SAME.
• ELEVATED TEMPERATURE

Remember: PATIENT WOULD HAVE:

• HIGH blood pressure,
• LOW respiration and pulse,
• HIGH temp.

Nursing Care

• MAINTAIN FLUID BALANCE: FLUID RESTRICTION (if possible)
• POSITION CLIENT: BED ELEVATED 30-45 DEGREES
• MAINTAIN A PATENT AIRWAY.
• HYPEROSMOTIC AGENTS (MANNITOL, OSMITROL)
• CORTICOSTEROIDS (DEXAMETHASONE)
• DIURETICS (FUROSEMIDE, LASIX): REDUCE CEREBRAL EDEMA
• ANTICONVULSANTS (PHENYTOIN, DILANTIN): PREVENT SEIZURES.

HEAD POSITION:

MIDLINE OR NEUTRAL POSITION

AVOID FLEXING OR EXTENDING.

IMPORTANT:

• PATIENT CAN ALSO MANIFEST THE “CUSHING’S TRIAD) WHICH ARE VITAL SIGN CHANGES THAT WILL SHOW A DECREASE IN RESPIRATIONS AND PULSE RATE BUT INCREASE IN BP.

FOR AN INFANT*(SYMPTOMS*)

• BULGING FONTANELS
• RESTLESSNESS & IRRITABILITY
• HIGH PITCHED CRY