hey everyone nurse Mike here from simple nursing.com today we're covering increased intercraanial pressure all the patho key signs and nursing care to keep your patients and your enclelex score safe now for all my members that subscribe to simple nursing grab your study guides to help this critical info stick when it matters most let's get started increased ICP is a must-note topic for the ENCLEX and nursing exams since it's very deadly and it relates to so many highly tested topics so be sure to pay attention and write all the key points down in this video so first off let's break down the word let the name help you here increased intraranial pressure just think high pressure inside the cranium the head which puts loads of pressure on the brain eventually squashing the brain stem which controls breathing and heart rate and this eventually kills the patient now as far as the causes just think of anything that can increase pressure inside the head from increased bleeding in the head from an aneurysm stroke we get a bursted blood vessel that now fills up the brain causing increased pressure or increased swelling and inflammation from a head trauma or even menitis so more inflammation means more pressure or even increased brain tissue like from a tumor now as far as the pathophysiology again just think this increased pressure compresses the brain so initially it compresses blood vessels that carry oxygen to the brain so less blood means less oxygen resulting in a change of level of consciousness from cerebral hypoxia that low oxygen to the brain so the key term here is reduced level of consciousness or decreased mental status write that down this is the earliest sign of increased ICP and even Hessie says that the earliest sign of increased ICP the answer was altered level of consciousness again just think low oxygen means low consciousness or mental status change also known as altered level of consciousness now for the signs and symptoms to write down so the earliest signs are typically the most tested on the enclicks so key terms again altered level of consciousness but they also call it irritability and restlessness as well as decreased mental status then we can see sleepiness as well as a flat affect and drowsiness now again the enclelex and exit exams love to focus on this since early detection saves lives now for moderate signs we see a headache that's constant and then another key term sudden vomiting that emmesis without nausea we must report this to the HCP or the provider now the big key term here is vomiting without nausea this was mentioned a few times by various exams and enclelex question banks pulling from our over 4,000 enclelex questions in our nursing school and enclelex memberships here's a common enclelex question so a common enclelex question asks which client is priority and it's typically the one with a closed head injury waiting for brain imaging who reports key terms here headache and emmesis of 200 mls without nausea so again write down those big key terms again the enclelex loves to ask about priority clients so emmesis without nausea is typically a priority finding now for the late deadly signs here as ICP builds it puts a lot of pressure on the brain stem at the base of the brain which controls the heart rate and breathing so this eventually leads to irregular breathing and other vitals so in the lungs we'll see irregular respirations known as cheny stoke respirations this is basically fast and slow breathing in the neck we see nucarigidity that stiff neck patients complain of they cannot flex the chin toward the chest write that down it's a big key word so just think all this pressure inside the brain is pushing down on that brain stem causing herniation now the key signs that the brain stem is affected is write this down the pupils will be fixed and dilated and sometimes unequal so dilated to 8 mm normally they're 2 to six now we want what's called doll's eyes basically eyes that move in the opposite direction when the head is turned this means that the brain stem is intact if the eyes stay fixed and if they're really blown or dilated when the head is turned this means the brain stem is affected now the other sign that we see is in the foot the babinsk's reflex where toes fan out when stimulated this is bad we want toes to curl down and not fan out it could mean that the brain stem is being crushed aka herniated now this finding is normal in an infant below one years old but not normal in an adult now later signs we'll see a seizure and comas as the brain gets further squished and then abnormal posturing we get decorticate where extremities go toward the core of the body and derate which was mentioned by ATI now dere is far worse the arms kind of flex out toward the sides and become rigid and extended so just think you cannot celebrate with dera brit it's far worse so a commonly missed enclelex question talks about a priority assessment finding for a client recovering from a head trauma select all that apply so option one eyes move in the opposite direction when the patient is turned yes this is a good sign the key term here is that the eyes move this is doll's eyes we do not want eyes to be fixed and dilated that means the brain stem herniation now option two extremities are contracted toward the core of the body no this is a bad sign that's decoricate any type of posturing is bad now option three fixed pupils that remain 8 mm that's the key term 8 mm and they're fixed when assessed with a pen light guys that's really bad fixed dilated pupils means brain stem herniation now option four and five are incorrect so level of consciousness that is not diminished since admission this is a good sign it means that the patient's not getting worse and option five grips that are 5x5 bilateral yes good strong grips are good and then number six toes that fan out when the sole of the foot is stroked remember that's very bad this is Babinsk's sign we want those toes to curl now one of the last signs to note is Cushing's triad huge Enclelex tip here so pay attention here think Cushing's triad we get crushing triad since the brain stem is being crushed by that ICP we get a crushed heart rate and respiratory rate since that brain stem controls those so we'll see widening pulse pressure with high BP that hypertension and low heart rate that brada cardia and very low respiratory rate known as decreased respirations on many question banks so for widening pulse pressure this just means that the blood pressure numbers are getting further apart very wide so sistolic blood pressure that top number is getting higher and then the diastolic blood pressure the number on the bottom is getting lower as well as the heart rate too so let the name help you here the blood pressure ends up wide apart with this widening pulse pressure so again Cushing triad just think crushing triad crushed heart rate and respiratory rate with a wide blood pressure as far as diagnostics the imaging CT scan is the first test we do to get a quick easy picture of the brain and to show the root cause of this increased ICP now don't get tricked it's not an MRI those are typically long and slow so the memory trick we use is think CT scan that CAT scan is like cat-like reflexes a very fast reading and then secondly no lumbar puncture aka spinal tap this can actually cause worsening ICP and for long-term patients we do ICP monitoring with a subacoid screw also known as a brain drain now normal ICP is between 5 to 15 so anything above 15 means that increased ICP is getting worse now the good news of this brain drain is that we get very accurate readings but the bad news is the high risk for infection like really high so that's why we only use it for very serious long-term patients like those in a coma now a tricky enclelex question is about a client found on the floor appearing lethargic with bleeding to the back of the head and a heart rate of 45 and a blood pressure that's pretty high what is the first action so the answer is to immediately do C-spine immobilization and then do a CAT scan that CT scan to rule out intercraanial bleeding now these kind of questions are very tricky right but on the enclelex and your nursing exams always remember assessment comes before intervention so for this low heart rate and high BP don't let the enclelex trick you here yes the blood pressure is high and you're probably thinking you have to give meds to lower it right but we must prioritize this brain bleed here since that will kill the patient the fastest and this is an assessment finding so we need a stat CT that picture of the brain and not drugs first looking for more tips and strategies for questions like the ones we just covered while our simple nursing membership includes exit prep lectures and thousands of questions across all nursing school and ENLEX topics now for nursing interventions to keep it really simple use the memory trick ICPs i for immobilize the head in C-spine some question banks said head in neutral position and log roll the patient as one unit c is for CO2 that is low remember lower CO2 means lower ICP below that 35 since carbon dioxide vaso dilates the brain resulting in more swelling from more blood flow so typically patients on ventilators we hyperventilate these patients to blow off CO2 and lower ICP so Hessie had a question about this stating that a client on a ventilator with increased PA2 the nurse receives an order to increase the respiratory rate on the ventilator this change should have what expected result on the patient's ICP and the answer was decreased ICP because we have decreased carbon dioxide now in terms of positioning we need to make sure the head of the bed is in semifallers position 30 to 35° or even higher here this promotes drainage and no flexion or bending of the extremities so remember this is a no flex zone here no ninja moves no hidden dragon no matrix type of stuff and lastly no coughing no sneezing or even blowing the nose and definitely key term here no valva maneuvers like holding the breath or bearing down to use the restroom this adds more pressure making the ICP even worse now Kaplan mentions that instructing a patient to exhale when turning or moving in bed remember no holding the breath exhaling so holding the breath could lead to that increased abdominal pressure which will increase pressure inside the brain and a common enclelex question talks about immediate intervention when a client with ICP states I will turn cough and deep breathe no we want to avoid all these things the key term here is no coughing and lastly S is for suctioning key term is 10 seconds or less and limit suctioning as much as possible and always before and after suctioning we use 100% oxygen now Hessie touched on all of these in a satic question stating interventions for increased ICP so the correct answer was position that is semifallers place the neck in neutral position teach the patient to avoid valva maneuvers position the patient by avoiding flexion of the hips waist or neck key term there is flexion and then lastly suction only as necessary but no longer than key term 10 seconds and another question interventions for increased ICP and ineffective breathing pattern select all that apply so once again suction no longer than 10 seconds 100% oxygen before and after suctioning and perform neuro checks using the GCS that Glasggo coma scale now switching gears here let's talk about the GCS this is used to measure level of consciousness and remember the earliest sign of that increased ICP was that mental status change so let's break down the GCS score real quick so a score of 15 is the highest score this means that the patient is fully conscious so we like high scores here as ICP goes up the GCS goes down so the key number here to know is less than 8 we must intubate since these clients are in a coma basically the ICP is getting so bad that the brain stem is being herniated basically crushed crushing the drive to breathe and the heart rate and the patient obviously slips into that coma so the priority here is to notify the provider immediately for any GCS numbers that are decreasing they should not be decreasing they should only be increasing here so the Hessie mentions a scenario of a GCS of seven stating that the patient will require complete care because they're in a coma so remember less than eight we inhabate because they're in a coma and a common enlex question talks about a client recovering from a head trauma with the GCS of 14 over 2 hours ago but now the GCS score is 11 guys we must report this to the HCP immediately again any decrease in GCS is priority to report now there was an interesting question from Kaplan here stating that a client with a traumatic brain injury and increased ICP with a GCS of 5 why is it important to provide eye care and the answer was to prevent coral irritation so remember let's break this down here gcs of 5 is less than 8 so the client will be in a coma and clients in comas may have eyes open so we want to prevent that corial irritation now as far as detailed scoring for the GCS that's covered in another video but it's a nice to know for the ENCLEX not a need to know since it wasn't really highly tested on any of the Enclelex question banks now we did see two questions talking about alertness in terms of spontaneously alert that alert without stimuli and orientation basically seeing if the client's confused so the Hessie mentions a patient replies with the correct name and location but incorrect year and date how should the nurse document this patient's response and the correct answer was alert and oriented to person and place now another common enclelex question here is which assessment best demonstrates the GCS so painful stimuli that is applied and the patient pulls away this is responsive to pain and a client responds to a nurse's question this is responsive to verbal so don't let the enclelex trick you here again this is not spontaneous since these clients are responding to a stimuli so responding to the pain or responding to the verbal cue now as far as treatments with pharmarmacology we want to decrease the swelling and also prevent seizures so for seizure prevention we can give phenitoin an anti-seizure drug and for the swelling we usually give steroids ending in zone like dexamethasone or even pheninobarbital which is a barbituate that decreases brain activity which decreases cerebral metabolism and decreases pressure this is what's called a sedation vacation or a medically induced coma but really the number one drug to know here is write this down manitol our osmotic diuretic now we did a whole segment in our pharmacology master course so let's play that segment right now now for osmotic diuretics we have manitol given to decrease cerebral edema with ICP that incraanial pressure like with patients with head injuries and swelling in the brain with menitis and it's even given for increased ocular pressure for glycom emergencies so the memory trick we use is manitol think man it hurts or man ICP hurts in the head or basically man my eyes hurt for manitol so the ATI mentions we give manitol for increased ICP and we assess the level of consciousness every hour and the Hessie mentions four key points for manitol it's used to decrease ICP for IV administration it cannot be given PO And one of the main side effects is edema which begins 30 to 60 minutes after administration okay you're probably thinking hold up here this is really interesting why would a diuretic which drains fluid from the body to the body why would it cause edema or fluid retention well the mechanism of action is it works by draining fluid out of the cell into the vascular spaces so swollen brain cells that have all that pressure causing the ICP get drained so all that fluid gets drained into the blood vessels which can put the body in fluid volume overload this leads to classic heart failure signs and symptoms like peripheral edema fluid in the extremities and even pulmonary edema fluid in the lungs so naturally a big side effect is heart failure so think HF for heart failure we get HF for heavy fluid all over the body now ATI mentions this when talking about manitol you monitor for signs and symptoms of heart failure specifically basilary cracks or basically crackles inside the bases of the lungs as well as pulmonary edema that fluid in the lungs now that's why the patho is so important here so thanks for watching this entire video to understand all of it thanks for watching did you know you can unlock beautifully handcrafted study guides act with key points and memory tricks from all our videos plus you'll get access to over,200 exclusive videos not on YouTube all neatly organized by nursing school topic to make that complex nursing knowledge actually stick you'll also gain thousands of practice questions written by current professors and 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