University:
West Coast University
Course:
NURS 100 | Fundamentals of Nursing
Academic year:

2022
Views:

72

Pages:

1
Author:

Alexa Livingston

ACTIVE LEARNING TEMPLATE: SYSTEM DISORDER ALT #3 STUDENT NAME: DISEASE/DISORDER PROCESS: INCREASED INTRACRANIAL PRESSURE (ICP) REVIEW MODULE CHAPTER: 14, 29 Alterations in Health (Diagnosis) Increased Intracranial Pressure Pathophysiology Related to Client Problem Changes in the brain's volume, cerebrospinal fluid (CSF) volume and/or blood volume that exceed the body's compensatory ability (change in volume). PRESSURE IS INCREASED IN PROPORTION TO VOLUME AND STIFFNESS (Wilson, p. 110). ASSESSMENT Risk Factors Individuals at risk: TBI, strokes, brain tumors, infections (e.g., meningitis), hydrocephalus Aggravating factors: Hypertension Seizures Epilepsy Stress Hypertensive crisis Hyperglycemia Expected Findings (changes in ICP) High ICP, midline shift, tonsillar herniation/brainstem edema, death. SIGNS: headache, nausea, vomiting, blurred vision, decreased level of consciousness. (NTP, p. 183) Laboratory Tests Arterial blood gases (ABGs). Blood work with culture and differential analysis. Osmolarity. Liver function. Diagnostic Procedures ICP monitoring. Spinal tap: 8-10 mmHg (2-10 mmHg is normal ICP). CT/MRI. X-Ray. Health Promotion and Disease Prevention Wear helmets in activities that have risk. Limit exposure to risk factors: Physical activity (e.g., rollerblading at night). Avoid headache-inducing activities (e.g., stress). SAFETY CONSIDERATIONS Maintain a stable body position. When client is discharged, instruct them on symptoms, medications, and diet that may cause recurrence. Patient safety during transport. COREP - COLLAPSE: Body position should be supine, and the head and upper trunk should be elevated. (NTP, p. 60). PATIENT-CENTERED CARE Nursing Care Head-up positioning. Fluid intake and output (urinary output). Body weight. Level of consciousness, pupils, vital signs. Monitor heart rate and blood pressure. Record changes in patient behavior. Medications Mannitol: osmotic diuretic for cerebral edema. Barbiturates: induced coma to reduce ICP in refractory ICP. Phenytoin: prevention of seizures. Opioids: pain and anxiety control. Client Education Educate family and patient on: Causes of ICP. Mechanisms of action of medications (e.g., antibiotics). Surgical and non-surgical interventions. Lifestyle changes: diet, exercise, medication adherence. Interprofessional Care Neurologist. Physical, occupational, speech therapists. Social worker. Rehabilitation facilities. Complications Brain compression and protrusion. Intracerebral hemorrhage. Cerebral circulatory disturbance. Secondary infection. Therapeutic Procedures Head-up positioning. Decrease external stimuli (e.g., quiet room). Comfort measures: Keep cool. Avoid tight clothing. Avoid stress. ORANGE ACTIVE LEARNING TEMPLATES THERAPEUTIC PROCEDURES A11