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NCLEX Review & Nursing School

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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

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