45: NEUROLOGIC PROBLEMS
MONITORING FOR INCREASED INTRACRANIAL PRESSURE
Most at risk for increased ICP resulting from edema during the first 72 hr.
... [Show More] after onset of a
stroke
May have worsening neuro changes starting within 24-48 after their endovascular
procedure from increased ICP
Assess these pt. Q 1-4 hr.
CHART 45-6 KEY FEATURES
Decreased LOC (lethargy to coma)
Behavior changes: restlessness, irritability, and confusion
HA
N/V (may be projectile)
Change in speech pattern/slurred speech:
o Aphasia
Change in sensorimotor status:
o Pupillary changes: dilated and nonreactive (“brown pupils”) or constricted and
nonreactive
o Cranial nerve dysfunction
o Ataxia
Seizures (usually within first 24 hr. after stroke)
Cushing’s triad:
o Severe HTN
o Widened pulse pressure
o Bradycardia
Abnormal posturing:
o Decerebrate
o Decorticate
>> INTERVENTIONS
For increased ICP experiencing a stroke:
o Elevate HOB – sitting them up is very important
o O2 therapy (for O2 < 94%)
o Maintain head in midline, neutral position – promotes venous drainage from the
brain
1
o Avoid sudden and acute hip or neck flexion during positioning
o Avoid the clustering of RN procedures – can elevate ICP even more
Not for neuro pt.
o Hyperoxygenate before and after suctioning
o Provide airway management to prevent unnecessary suctioning and coughing
that can increase ICP
o Maintain quiet environment if pt. has a HA
o Keep the room lights low to accommodate and photophobia
o MT BP, heart rhythm, O2 sat, blood glucose, and body temp to prevent secondary
brain injury and promote positive outcomes after stroke
MD usually like BP to be slightly elevated after a stroke (SBP = 140-150)
CRITICAL RESCUE!! – Be alert for S/S of increased ICP in the head injury and report any
neuro deterioration to the MD or Rapid Response Team immediately!
o The 1st sign of increased ICP is a declining LOC [Show Less]