NCLEX Review & Nursing School

Increased Intracranial Pressure

Increase in pressure within the cranium.  Usually caused by trauma, edema and hemorrhaging.

Interventions:

• * No vagal stimulation with this patient
• Implement seizure precautions
• maintain patent airway

Assessment

• Earliest Sign: decrease in LOC, restlessness and confusion
• Changes in vital signs (may be a late sign).
• Systolic blood rises while diastolic pressure remains the same.
• Elevated Temperature

Nursing Care

• Maintain fluid balance: fluid restriction of 12-1500 ml. may be ordered.
• Position client with head of bed elevated 30-45 degrees.
• Administer Medications as ordered which can include:
• Hyperosmotic agents (Mannitol, Osmitrol) Corticosteroids (dexamethasone)
• Diuretics (furosemide, lasix) to reduce cerebral edema
• Anticonvulsants (phenytoin, Dilantin) to prevent seizures.

The most common symptoms for client with and increased in ICP would include: A blurred vision, changes in cognition and changes in level of consciousness.

• 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