Intracranial Pressure - Lab Quiz

A patient with a head injury has an arterial blood pressure is 92/50 mmHg and an ICP of 18 mmHg. Which action by the nurse is appropriate?

a. Document and continue to monitor the parameters.

b. Elevate the head of the patient's bed

c. Notify the health care provider about the assessments.

d. Check the patient's pupillary response to light

C.

The patient's perfusion pressure is only 46 mmHg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and to increase arterial BP. Documentation and monitoring are inadequate responses to the patient's problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information.

A patient has a systemic BP of 120/60 mmHg and an ICP of 24 mmHg. The nurse determines that the cerebral perfusion pressure (CCP) of this patient indicates

a. high blood flow to the brain

b. normal ICP

c. impaired brain blood flow

d. adequate cerebral perfusion

C.

The patient's CCP is 56, below the normal of 70 to 100 mmHg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mmHg.

A 41 yo patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral brain swelling. Which nursing intervention will be included in the plan of care?

a. Encourage coughing and deep breathing.

b. Position the patient with knees and hips flexed.

c. Keep the head of the bed elevated to 30 degrees.

d. Cluster nursing interventions to provide test results.

C

The patient with ICP should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic and ICP

After evacuation of an epidural hematoma, a patient's ICP is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider?

a. Pulse 102 bpm

b. Temperature 101.6 F

c. ICP 15 mmHg

d. Mean arterial pressure 90 mmHG

B

Temperature 101.6

When a patient's ICP is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?

a. Oral temp 101.6 F

b. ICP 15 mmHg

c. Mean arterial pressure 70 mmHg

d. Apical pulse 106 beats/min

A

Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; the temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

The nurse is caring for a patient who has just had neurosurgery. To assess for ICP, what would the nurse include in the assessment?

a. CNs, motor function and sensory function

b. DTRs, vital signs, and coordinated movements

c. Level of consciousness, motor function, pupillary response, and vital signs.

d. Mental status. DTRs, sensory function, and pupillary response

C

Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing ICP. The nurse should use an abbreviation of the neurologic examination in the following sequence level of consciousness, motor function, pupillary response, and vital signs.

A 41 yo patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

a. Encourage coughing and deep breathing.

b. Position the patient with knees and hips flexed.

c. Keep the head of the bed elevated to 30 degrees.

d. Cluster nursing interventions to provide rest periods

C

The patient with increased ICP should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions, increases ICP, clustering interventions will progressively elevated ICP. Coughing increases intrathoracic pressure and ICR.

A patient has increased ICP and a ventriculostomy after a head injury. Which action can the nurse delegate to the UAP who regularly work in the ICU?

a. Document intracranial pressure every hour.

b. Turn and reposition the patient every 3 hours.

c. Check capillary blood glucose level every 6 hours.

d. Monitor CSF color and volume hourly.

C

Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill Monitoring and documentation of CSF color and ICP require an RN because of the level of education and scope of practice. Although repositioning patients is frequently delegated to the UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN

A patient admitted with a diffuse axonal injury has a systemic BP of 106/52 and an ICP of 14 mmHg Which action should the nurse take first?

a. Document the BP and ICP in the patient's record

b. Report the BP and ICP to the health care provider

c. Elevate the head of the patients' bed to 60 degrees

d. Continue to monitor the patient's vital signs and ICP

B

Calculate the cerebral perfusion pressure (CCP): (CCP = mean arterial blood pressure [MAP] - ICP). MAP = DBP +1/3 (systolic blood presure [SBP] - diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CCP is 56 mmHg, which is below the normal of 60 to 100 mmHg and approaching the level of ischemia and neuronal death. Immediate changes in he patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

Family members of a patient who has a TBI ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best?

a. "This type of monitoring system is complex and it is managed by skilled staff."

b. "The monitoring system helps show whether blood flow to the brain is adequate."

c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure.

d. "This monitoring system helps show whether blood flow is adequate."

D

"This monitoring system helps show whether blood flow is adequate."

During an assessment of a 22 yo woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest?

a. Injury to the right eye

b. Increased intracranial pressure

c. Test inaccurately performed

d. Normal response after a head injury

B

In a person with a brain injury, a sudden, unilateral, dilated and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing ICP pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.