Page 2014 - Saunders Comprehensive Review For NCLEX-RN

impede the absorption of CSF, affect the functioning
of nerve cells, and lead to brainstem compression and
death.

B. Assessment

1. Altered level of consciousness, which is the most
sensitive and earliest indication of increasing ICP
2. Headache
3. Abnormal respirations (see Box 58-2)
4. Rise in blood pressure with widening pulse pressure
5. Slowing of pulse
6. Elevated temperature
7. Vomiting
8. Pupil changes

9. Late signs of increased ICP include increased

systolic blood pressure, widened pulse pressure, and
slowed heart rate.
10. Other late signs include changes in motor function
from weakness to hemiplegia, a positive Babinski’s
reflex, decorticate or decerebrate posturing, and
seizures.

C. Interventions

1. Monitor respiratory status and prevent hypoxia.
2. Avoid the administration of morphine sulfate to
prevent the occurrence of hypoxia.
3. Maintain mechanical ventilation as prescribed;
maintaining the PaCO at 30 to 35 mm Hg (30 to
2
35 mm Hg) will result in vasoconstriction of the
cerebral blood vessels, decreased blood flow, and
therefore decreased ICP.
4. Maintain body temperature.
5. Prevent shivering, which can increase ICP.
6. Decrease environmental stimuli.
7. Monitor electrolyte levels and acid–base balance.
8. Monitor intake and output.
9. Limit fluid intake to 1200 mL/day.
10. Instruct the client to avoid straining activities, such as
coughing and sneezing.
11. Instruct the client to avoid Valsalva’s maneuver.

For the client with increased ICP, elevate the head of the bed

30 to 40 degrees, avoid the Trendelenburg’s position, and prevent
flexion of the neck and hips.
D. Medications (Box 58-7)

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