NUR 335 Quiz 4 Test Questions and Detailed Answers
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Course
NUR 335
Institution
NUR 335
Increased Intracranial Pressure (ICP) Higher than normal pressure within the cranium Destroys healthy brain tissue and alters mental function
Causes Tumors or lesions Accumulation of fluid within the ventricular system Bleeding or trauma Edematous brain tissue Trauma
Complications Brain death Car...
NUR 335 Quiz 4 Test Questions and
Detailed Answers
Increased Intracranial Pressure (ICP) ✅Higher than normal pressure within the
cranium
Destroys healthy brain tissue and alters mental function
Causes
Tumors or lesions
Accumulation of fluid within the ventricular system
Bleeding or trauma
Edematous brain tissue
Trauma
Complications
Brain death
Cardiac arrest
Respiratory insufficiency or arrest
Pathophysiology
Rigid skull allows little room for expansion
Brain compensates for increases in ICP limits blood flow to head
displaces CSF into the spinal canal
increases absorption or decreases production of CSF by withdrawing water from the
brain tissue into the blood and excreting it via the kidneys
Age Specific Assessment Findings
Infants
Bulging fontanels without normal pulsations
Irritability
Shrieking, high-pitched cry
Increased head circumference
Decreased LOC
Altered feeding pattern
Distended scalp veins
Top Three Signs of ICP in Infant
Bulging fontanels without normal pulsations
Shrieking high-pitched cry
Increased head circumference
Children
Vomiting with or without nausea
,Headache
Diplopia
Seizures
Top three signs of ICP in children
Vomiting
Headache
seizures
Other signs common to any age
Lack of interest
Decreased motor activity
Increased sleep
Weight loss
Lethargy that progresses to drowsiness
Increased BP, decrease HR, decreased RR
Late signs
Diminished response to painful stimuli
Altered pupil size and reactivity
Posturing; Decorticate, decerebrate
Cheyne-stokes respirations
Papilledema
Management
Subdural tap
Ventricular tap
Hyperventilation via mechanical ventilation to reduce CO2
Nursing Interventions
Monitor neuro status including LOC and pupil size and reactivity
Monitor ICP; report deviations, maintain patency and calibration of
Cerebral Palsy ✅Non-progressive neuromuscular disorder of varying degree
Damaged area of brain that controls motor function
Types
Spastic
, Dyskinetic or athetoid
Ataxic
Mixed
Causes
Anoxia before, during or after birth
Infection
Trauma
Assessment findings (all types)
Delayed gross motor development
Abnormal motor and coordination, may be early ie; poor sucking, feeding difficulty
Abnormal posture at rest or when changing position
Altered muscle tone
Increased or decreased resistance passive ROM
Opisthotonic postures (exaggerated arch of the back)
Spasticity of the hip muscles and lower extremities
Abnormal reflexes
Persistent primitive reflexes
Other disabilities
Mental retardation of varying degrees
Seizures
Attention deficit disorder
Sensory deficits
Vision (strabismus)
Hearing
speech
Findings per type
Ataxic
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