hello guys,..!
i have not yet been post a lot here, because im so busy this day,but you know i have just something to tell about this topic...
INCREASE INTRA CRANIAL PRESSURE
Do you know what is this? I will just take an outline out of the books that I've read...
Increase Intracranial pressure is due to increase in 1 intracranial components.
Some Predisposing factors are:
- head injury,tumor,localized abscess
- hemmorhage,cerebral edema, hydrocephalus,
- inflammatory conditions like meningitis and encephalitis
Signs and symptoms are
a,)change or decrease LOC- it may be restlessness to confusion
-disorientation to lethargy and stupor to coma.
b.)Headache- patient can experienced projectile vomitting
-Papilledima(edema of optic disk- outer surface of retina.)
c.)Uncal Herniation-unilatateral dilation of pupil.
Tentorial herniation-bilateral dilation of pupil
d.)Possible seizure
GUYS you need to bear in mind that CHANGE IN VITAL SIGNS of the patient is always the LATE SYMPTOMS OF ICP.
- Increased BP-systolic increase, diastole is same
- Decrease HR-
- Decrease RR-you can observe CHEYNE STOKES-between period of apnea or hyperapnea with periods of apnea.
- Increase Temperature
NURSING PRIORITY
A..Maintain patent airway and adequate ventilation.
- Prevention of hypoxia-(there is decrease tissue oxygenation) and hypercarbia( there is increase in CO2 retention).
- Late symptoms of hypoxia...B-bradycardia Early symptoms ...R- restlessness E-extreme restlessness A-agitatation D-dyspnea T- tachycardia
B..Assist mechanical ventilation.
- maintain patent airway
- monitot v/s and i and o
- elevate head of bed 30-45 degrees, neck in neutral position unless contraindicated to promote venous drainage
- limit fluid intake 1200-1500ml/day
- prevents complication of immobility
C..Prevent increase of icp by:
- maintain quite and comfort environment
- avoid use of restraint because it can lead to fracture
- always siderails up
- instruct patient to avoid the ff:- Valsalva maneuver or bearing down, avoid straining of stool.-give laxative or stool softener
- -Excessive cough,excessive vomiting and lifting heavy objects
D. Administered meds ordered.
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