Question

Jane Smith, an 82-year-old female client, was admitted after falling on ice and hitting the back of her head. She is lethargic, but awakens and will talk, but slurs some of her words. She is restless in bed. The LPN/LVN awakened the client to assess her vital signs and perform a neurological assessment. The client stated she has a headache especially in the morning or after she coughs or sneezes that quickly goes away. She turned her head away from the nurse and vomited without any nausea. The nurse needs to provide nursing care to decrease the increased intracranial pressure the client is experiencing.

1. What are the signs and symptoms the client exhibited that support increasing intracranial pressure?
2. What nursing care should the nurse provide to help decrease the increased intracranial pressure the client is experiencing?
3. ICP is the pressure created by 3 components in the cranial cavity. Name these three.
4. Describe Cushing's Triad. Why is this an important finding?
5. What is the difference between decorticate posturing and decerebrate posturing? Which is worse?
6. Your client has the following assessment findings. Eye Opening to sound only. Verbal Response. The client is grunting and not speaking any words. Motor Response is normal flexion. What is the rating on the Glasgow Coma Scale? What should you do?

Answer 1

Answer: The signs and symptoms the client exhibited that support increasing intracranial pressure are the headache, vomiting and she is feeling lethargic.

The nurse should provide care to reduce the intracranial pressure as by keeping the head of the patient on thirty degree angle. Secondly the nirse could adjust the neck of patientin neutral position. A the nurse should maintain a normal body temperature as well as oxygen levels.

ICP is the pressure created by 3 components in the cranial cavity are:

• brain
• cerebrospinal fluid
• blood

Cushing's Triad causes increase hypertension. This will causes increased blood flow. Hence this will directly elevates the intracranial pressure. Hence it is important to control it.