Increased cranial pressure PDF

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Summary

Health and Illness Across the Lifespan...

Description

MEDICAL SURGICAL NURSING: NEURO 1.9.5

NURSE ANGIE 2018

Increased intracranial pressure Pressure on the brain from increased swelling on the brain.

Assessment Can be caused by trauma, intracranial hemorrhage, tumors, hydrocephalus, edema, or inflammation. Increased ICP impaired cerebral circulation, decreases absorption of CSF, affects the functioning of nerve cells and can lead to brain stem herniation or death. Normal ICP ranges from 5-15 mmHg anything above 20 indicates immediate treatment.

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CPP • Pressure that pushes blood

to the brain. • Normal CPP 60-100 mmHg • When CPP falls too low < 50 mmHg !brain death occurs due to cerebral hypoxia. • CPP= MAP-ICP

INFLUENCING FACTORS • Body temperature: Fever • Oxygenation : Elevated C02

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causes vasodilation !or hypoxia • Body position • Arterial or Venous pressure • Intra Abdominal or thoracic

pressure: vomiting, hip flexion"

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P: Position, elevate HOB 30-35 degrees, midline. Avoid flexion of head or hips R: Respiratory status monitoring, prevent hypoxia and hypercapnia. Maintaining a PCO2 at 30-35 mmhg will decrease ICP by causing vasoconstriction Suction for only 15 seconds at a time. !Keep peep low with mechanical ventilation. E: Elevated temp, lower body temp, prevent shivering, this can increase ICP. administer antipyretics, cool blankets, decreased room temp. S: Systems to monitor, frequent neuro checks, glasgow coma scale, S: Straining activities to avoid: Vomiting, sneezing, valsalva, keep a calm environment and avoid restraints. U: Unconscious patient care: avoid morphine to avoid hypoxia, monitor lung sounds, ROM, eye care, blood clots. R: !RX: administer vasopressors,IVF, !barbiturates to decrease brain metabolism, MAINTAIN SBP >90...