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IntraCrainial Prassure, Hyperventilate, o2, maintain airway preneed intubation, protect eyes, reduce activity, avoid straining, Valsalvas Manuver, Nursing Interventions Nursing Interventions: Assisting the client with hyperventilation to expell CO2 thus reducing vasodilation. Assess pules and respirations, blood pressure looking for widening pulse pressures. Assessing temperature, hyperthermia with damage to the hypothalamus, or extreamily hypothermic with increased ICP that is not from an infectious cause. Assess the ability to move. The reaction to pain. Assess eyes. Assess all the crainial nerves but most important assess the pupils. Assess Glascow Coma Scale Cushings triad: HTN, Bradycardia Bradypnea, Cardinal Sign for ICP Headaches, Severe crushing pressure., Cushings triad: HTN Bradycardia Bradypnea Cardinal Sign for ICP Signs and Symptoms Signs & Symptoms: Increased pressure in one part of the brain causes decreases perfussion on other parts of the brain causing hypoxia Metabolic Acidosis causes vasodilation. Normal ICP is 2-15 mmHg. Metabolic Acidosis (increased CO2, decreased O2, and a decreased pH level in the blood. Any increase in O2 reduces vasodilation causing further increases in CO2. Fixed and dilated pupils greater than 6mm in diameter and occurs of a mid brain lesion or cerebral hypoxia. This is a sign used to tell if the client is likely in a state of brain death and the cerebral hypoxia is at a degree that is normally not reversable., Cushings triad: HTN Bradycardia Bradypnea Cardinal Sign for ICP Signs and Symptoms Level of Consciousness: First loss of abstract thinking Concrete thinking is able. How are you feeling no answer Are you in pain yes or no slowness of thinking. Inability to give immeadiate response. Inability to remember to give immeadiate response. Inattentiveness, not following the conversation. especially after closed head injury. Continue deterioration will go to confusion and disorientation. feeling that things are going on around them but not aware of time sequences or who is doing things. Progressing to stupor then coma., Headaches: Menningetis, Increase in ICP, A headache that you wake up with in the morning (typical with ocipital migraine, and HTN) Headaches accompanied by projectile vomiting. Signs and Symptoms Signs & Symptoms: Increased pressure in one part of the brain causes decreases perfussion on other parts of the brain causing hypoxia Metabolic Acidosis causes vasodilation. Normal ICP is 2-15 mmHg. Metabolic Acidosis (increased CO2, decreased O2, and a decreased pH level in the blood. Any increase in O2 reduces vasodilation causing further increases in CO2. Fixed and dilated pupils greater than 6mm in diameter and occurs of a mid brain lesion or cerebral hypoxia. This is a sign used to tell if the client is likely in a state of brain death and the cerebral hypoxia is at a degree that is normally not reversable., Diagnostic Procedures & Medications: CT Scan which tells about tissue and blood flow throught the brain. MRI tells about tissue movement and pressures in the brain. PET Scan tells about the energy and electrical activity in the brain. Ultrasound of the brain is usually used in children looking for intraventricular hemorrhage, has been used for dx of CVA as well. Corticosteriods- Decadron Anticonvulsants- Dilantin Increased Intracrainial Pressure Risk Factors: CVA, trauma, Hemmorragic CVA, Menningitis also seen in tumors, espcially solit tumors of the brain, since it is a closed system any increase in the brain will cause an increase in the ICP. An increased CO2, decreased O2, and a decreased pH level in the blood (aka Metabolic Acidosis) will cause an increase in ICP., Headaches: Menningetis, Increase in ICP, A headache that you wake up with in the morning (typical with ocipital migraine, and HTN) Headaches accompanied by projectile vomiting. Signs and Symptoms Level of Consciousness: First loss of abstract thinking Concrete thinking is able. How are you feeling no answer Are you in pain yes or no slowness of thinking. Inability to give immeadiate response. Inability to remember to give immeadiate response. Inattentiveness, not following the conversation. especially after closed head injury. Continue deterioration will go to confusion and disorientation. feeling that things are going on around them but not aware of time sequences or who is doing things. Progressing to stupor then coma., Visual acuity and Papiloedema, blurred vision double vision, a detached retina and a narrow field of vision. Client will be at risk for permanent blindness as well as increased intracrainial pressure. Signs and Symptoms Pupil Reactivity: These are controlled by crainial nerve III, atonic is on that is dialated, and fails to react or reacts very slowly to light and is often accompanied by diminished reflexes (seen in diabetic neuropathy, alcoholism) Pinpoint pupils fixed- myosis - indicated severe CVA or damage to the brainstem ɚmm in diameter. Dialated pupils are usually seen in unconsiouness and cardiac arrest, in head injury and at death. Constricted pupils are usually seen with medications esp Morphine, and brainstem injury. In medication overdose pinpoint pupils with narcotics and dilated pupils with barbituates., Visual acuity and Papiloedema, blurred vision double vision, a detached retina and a narrow field of vision. Client will be at risk for permanent blindness as well as increased intracrainial pressure. Signs and Symptoms Level of Consciousness: First loss of abstract thinking Concrete thinking is able. How are you feeling no answer Are you in pain yes or no slowness of thinking. Inability to give immeadiate response. Inability to remember to give immeadiate response. Inattentiveness, not following the conversation. especially after closed head injury. Continue deterioration will go to confusion and disorientation. feeling that things are going on around them but not aware of time sequences or who is doing things. Progressing to stupor then coma., Posturing: Decorticate Positioning- everything turns into the core of the body. Flexion internal rotation of the lower extremities and the arms flex up. Damage to the gray matter. Decerabate Position- the client is extended out rigid extention and abduction hyperpronation of the upperextremities and extention of the lower extremities and this demonstrates damage to the brainstem. Signs and Symptoms Pupil Reactivity: These are controlled by crainial nerve III, atonic is on that is dialated, and fails to react or reacts very slowly to light and is often accompanied by diminished reflexes (seen in diabetic neuropathy, alcoholism) Pinpoint pupils fixed- myosis - indicated severe CVA or damage to the brainstem ɚmm in diameter. Dialated pupils are usually seen in unconsiouness and cardiac arrest, in head injury and at death. Constricted pupils are usually seen with medications esp Morphine, and brainstem injury. In medication overdose pinpoint pupils with narcotics and dilated pupils with barbituates., Projectile Vomiting: without nausea is a cardinal sign of increased ICP. Due to pressure on the vomiting trigger zone on the brain. Signs and Symptoms Level of Consciousness: First loss of abstract thinking Concrete thinking is able. How are you feeling no answer Are you in pain yes or no slowness of thinking. Inability to give immeadiate response. Inability to remember to give immeadiate response. Inattentiveness, not following the conversation. especially after closed head injury. Continue deterioration will go to confusion and disorientation. feeling that things are going on around them but not aware of time sequences or who is doing things. Progressing to stupor then coma.