Neuro 1. What are the signs of increased ICP in infants? Tense bulging fontanels(firm and bump), separated cranial sutures, irritability, high- pitched cries, increased head circumference, distended scalp veins, changes in feeding, sunset eyes 2. What are the signs of increased ICP in children? Headache, nausea, vomiting, diplopia (double vision), blurred vision, seizures 3. What are the late signs of increased ICP? Bradycardia, lowered level of conscious, decreased motor response to command (decreased grip strength), decreased response to pain, alterations in pupil size and reactivity, posturing, cheneys-stokes respirations, papilledema, coma 4. What is the cushings triad? It is a neurological response to increased ICP. It includes bradycardia, irregular respirations, and a widening pulse pressure (increased systolic, decreased diastolic) 5. What is decerebrate posturing? What does it happen in the brain stem? Toes point downwards and arms and feet turn out, and the head/neck arch backwards. Indicates damage below the mid-brain/brain stem. *more serious than decorticate 6. What is decorticate posturing? Where does it happen? Arms are bent in to the body and fists are clenched, possibly held against the chest. Toes point together. Damage is above the mid-brain/brain stem 7. What is papilledema? Optic disk swelling 8. What are cheney-stokes respirations? Shallow breaths with varied breathing that can result in dyspnea and apnea 9. How do you treat increased ICP? Reduce the blood flow and decrease cerebral spinal fluid 10. How do you reduce blood flow for IICP? Give mannitol- reduces fluid volume, especially in the brain *monitor serum osmolality and sodium! Give 2/3 maintenance fluid (need 100ml/hr give 66 ml/hr) Want Co2 between 30-35 to induce hypocapnia, which decreases blood flow to brain (vasoconstrict) 11. How do you decrease cerebral spinal fluid? Place a shunt (ventriculostomy) Elevate HOB to 30-40 to increase CSF drainage and maximize venous output Aggressively treat fevers- antipyretics! 12. What are nursing considerations for caring for an unconscious child? Pain control measures Quiet environment Control ICP- minimize coughing, vomiting, constipation Minimal stimulation- no young visitors, use a calming touch, whisper to them, visitors are quiet, no TV, closed curtains, soothing and soft music 13. Nursing interventions for an unconscious child
Maintain a patent airway Position for optimal ventilation Avoid activities that could increase ICP Speak to the patient through cares
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- Spring '17
- Traumatic brain injury, Cerebrospinal fluid, Spina Bifida