A nurse is caring for a child who has increased intracranial pressure and is unconscious

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• The assessment and management of elevated ICP are performed jointly in practice. Increased ICP can result from bleeding in the brain, a tumor, stroke, aneurysm, high blood pressure, or brain infection. A child is admitted to the pediatric intensive care unit for a submersion injury. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? Flaccid paralysis of all extremities 2. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. B) Registers normal body temperature. Periodic or irregular breathing, What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child? a Apr 15, 2022 · Infants with increased ICP may experience different symptoms than older children or adults, although the most frequent signs and symptoms of increased ICP are listed below. This enhances gravity flow through the shunt and helps to reduce ICP. Which lab measurement should prompt the nurse to notify the health care provider?pH of 7. Adequate autoregulation of blood flow Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a patient with increased intracranial pressure who is receiving mechanical ventilation. Hypotension D. Follow-Up Appointment. ) Restlessness and confusion d. C) Normal for this child. Which intervention should the nurse include in the care plan to reduce ICP?, A client recovering from a stroke is diagnosed with pseudobulbar affect. The brain of a term infant weighs less than half of the weight of the adult brain. Level of consciousness and verbal response c. Provide environmental stimulation. The nurse has established a goal to maintain intracra- nial pressure (ICP) within the normal range. dizziness Oct 24, 2022 · RECOGNITION. Study with Quizlet and memorize flashcards containing terms like What nursing intervention is used to prevent increased intracranial pressure (ICP) in an unconscious child? Suction the child frequently. If you have any questions, be sure to ask your doctor or nurse. It is very important to keep all appointments. Papilledema is a common manifestation of increased intracranial pressure in the very young child. Which assessment finding supports this suspicion? (Select all that apply. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38. INCORRECT: Routine suctioning of the endotracheal tube is poorly tolerated, not recommended, and raises intracranial pressure. Which additional intervention is most important for the nurse to perform?, The nurse cares for a 7-year-old child with new-onset seizure disorder. Increased ICP has serious complications, including long-term (permanent) brain damage and death. Stroke, ICP, TBI. irritability D. Which of the following interventions should the nurse recommend? 1. The left side of the body. Here, we discuss the Study with Quizlet and memorize flashcards containing terms like Priority finding to report for a brain tumor=, A nurse is caring for an adolescent who has sustained a closed head injury. Which action should the nurse take first? a. A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea Jan 11, 2019 · Doctors call the pressure inside a person’s skull the intracranial pressure or ICP, and it can increase with a head injury or medical condition, such as fluid on the brain. ) Large amounts of very dilute urine c. Eye opening and verbal and motor response d. Increased intracranial pressure is a rise in the pressure inside the skull that can result from or cause brain injury. In case of increased ICP, the surgeon may prescribe elevation of the head of the bed and allowing the child to sit up. Pathophysiology. In more severe cases, close neurological monitoring and consultation with neurology and neurosurgery are important. 8 degrees F). Study with Quizlet and memorize flashcards containing terms like An injury to which part of the brain will cause a coma?, What finding is a clinical manifestation of increased intracranial pressure (ICP) in children? 1. Delirium b. Confusion, agitation, and restlessness are subtle clinical manifestations of. Changes in BP are a late sign, reflecting pressure on the brainstem. Which instruction Study with Quizlet and memorize flashcards containing terms like A 9-year-old client who suffered a head injury has strabismus. The nurse has documented that a child's level of consciousness is obtunded. C. decerebrate posturing E. It requires medical care right away. A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury. " What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. 5º C). A decrease in the liver enzymes D. Providing stool softeners or laxatives as ordered, Which assessment finding would be the earliest and most A drop in blood pressure 4. Avoid using narcotics or sedatives to provide comfort and pain relief. Increased Head to SimpleNursing’s OFFICIAL website here: https://bit. Monitor fluid intake and output carefully to avoid fluid overload and cerebral Study with Quizlet and memorize flashcards containing terms like 1. An increase in the blood glucose level C. monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. Increased heart rate E. have the client perform huff coughing hourly 2. headache B. The management of elevated ICP in children, the management of hydrocephalus in children, the evaluation of stupor and coma in children, and initial management of children with severe traumatic brain injury are discussed separately: (See Jul 31, 2023 · Nursing care must pay close attention to changes in neurologic status, any change in vitals such as an increasingly erratic heart rate, development of bradycardia, accurate and equal intake and output when having diuresis, and maintenance of proper blood pressure. The child's parents express guilt over the injury to the nurse. 2 Limitation of stimuli that increase intracranial pressure Increased intracranial pressure is associated with a high risk for mortality; stimuli must be minimized. Restlessness, A nurse is monitoring a client who has a leaking cerebral aneurysm. Which response by the nurse is best for this situation? a. This causes pupillary dilation on the side of the pressure. Study with Quizlet and memorize flashcards containing terms like Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Intracranial pressure and level of consciousness, The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hr ago. ) Bradycardia b. Abstract. Increased blood pressure, The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil ANS: A, B, C, E. We have an expert-written solution to this problem! The nurse is caring for a client with increased intracranial pressure as a result of head injury. Which finding is most likely an indication of the body's response to these findings? Jun 20, 2024 · A nurse is caring for a 7-year-old child in the pediatric intensive care unit who has increased intracranial pressure as a result of head trauma. Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. Which action should the nurse perform first? What is the priority nursing intervention for this client? 1 Changing position every two hours 2 Keeping a serial record of the pulse 3 Performing range-of-motion exercises 4 Monitoring for increased intracranial pressure, A 2½-year-old boy who has undergone surgery to revise a ventriculoperitoneal shunt is to be discharged. Diplopia, blurred vision d. D. Increased ICP has serious complications A. The client is being monitored for increased intracranial pressure (IICP). A nursing instructor asks the student about this type of herniation. (Pinto et al. The priority nursing intervention is to. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. No specific treatment exists for Reye syndrome; supportive care is based on the stage of the Study with Quizlet and memorize flashcards containing terms like A 9-year-old client who suffered a head injury has strabismus. Which arterial blood gas result indicates optimal oxygenation for the patient?, The nurse is teaching the caregiver of a patient diagnosed with increased intracranial pressure about care while at home. Blood Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). 4. Jun 29, 2024 · Late signs of ICP in an infant or child include bradycardia, alteration in pupil size and reactivity, decreased motor response, extension or flexion posturing, and Cheyne-Stokes respirations. " b. Aligning the neck with the body b. b. Indications of increased intracranial pressure B. 2. avoid using narcotics or sedatives to provide comfort and pain relief. The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion. Behavioral changes. The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? a. Hemiparesis E. Test the discharge for presence of glucose. Establish an adequate airway. A 55-yr-old patient who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy. Medical Management. decreasing intracranial An obstruction of the shunt can lead to increased intracranial pressure (ICP). The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. Drowsiness C. Develop a comprehensive understanding of Reye’s Syndrome, including its pathophysiology, clinical manifestations, and the populations most at risk. an insignificant finding 2. Which action is considered unsafe? a. A presence of protein in the urine 6 days ago · A nurse is contributing to the plan of care for a client who has increased ICP following a closed-head injury. The nurse should prepare for this patient to have a feeding tube placed. Study with Quizlet and memorize flashcards containing terms like 1. These motor centers control vomiting. Cerebrospinal fluid (CSF) Blood. The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Impaired blood flow to the brain d. A bulging anterior fontanel *hydrocephalus :A build-up of fluid in the cavities deep within the brain. The infant has 150 milliliters of cerebrospinal fluid compared with 50 milliliters in the adult. The nurse is caring for a client in the neurological ICU with head trauma. Jul 31, 2023 · The clinical presentation of increased intracranial pressure can easily be mistaken for other issues, such as intoxication, stroke, infection, or post-ictal state. Adduction of the arms at the Study with Quizlet and memorize flashcards containing terms like The nurse caring for a 3-year-old child with meningitis should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply. c) Observe for signs and symptoms of cerebrospinal fluid leakage. elevate the head of the bed to 30 degrees. 1. Monitor fluid intake and output carefully to avoid fluid overload and cerebral You may give your child his normal foods unless your doctor tells you otherwise. Isotonic or hypertonic fluids would be indicated for this patient. , Which of the following phrases describes a characteristic of most neonatal Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient with increased intracranial pressure. Chapter 38: Nursing Care of the Child With an Alteration in Intracranial Regulation/Neurologic Disorder - Page 1352. "The monitoring Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Headache. Weakness. give tepid sponge baths to reduce fever because antipyretics are contraindicated. Study with Quizlet and memorize flashcards containing terms like What finding is a clinical manifestation of increased intracranial pressure (ICP) in children? a. Answer: B. The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. B) Avoid using narcotics or sedatives to provide comfort and pain relief. . D) A sign that this child has a spinal cord injury. Blurred vision D. The infant would have a tense, bulging fontanel and an increased head circumference. If you have not been given an appointment, call the doctor's office. continue to monitor temperature. The order is for mannitol 1. Dextrose 50% and water is a treatment for status epilepticus. Renal failure and cardiogenic shock aren't complications A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. The nurse knows that most likely, the client has a diagnosis of, A client was A. Sunken fontanel c. , The nurse is caring for an infant who sustained a head injury during a fall. High blood flow to the brain b. elevate the clients Study with Quizlet and memorize flashcards containing terms like A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently & says she wants to die. Notify the health care Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client with a traumatic head injury and suspects increased intracranial pressure (IICP). Apr 23, 2024 · INTRODUCTION. The nurse would assess the child most carefully for what finding? - Indications of increased intracranial pressure - An increase in the blood glucose level - A presence of protein in the urine - A decrease in the liver The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. Flexion posturing d. Administer prescribed IV mannitol. Study with Quizlet and memorize flashcards containing terms like The nurse who is concerned about increased intracranial pressure in an infant should assess for:, The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. Reduced alertness. Report of headache B. Administer Tylenol (acetaminophen) via nasogastric tube. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP). Which of the following are clinical manifestations of increased intracranial pressure (ICP)? Select all. increased intracranial pressure (ICP). ) Widened pulse pressure, The nurse is caring for the client with increased intracranial pressure. Corticosteroids are indicated to treat inflammation. Determine whether a neck injury is present, Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting Study with Quizlet and memorize flashcards containing terms like Which method is used to help reduce intracranial pressure?, A patient is admitted to the hospital for management of an extrapyramidal disorder. A) Typical for a sleeping child at this age. The nurse is caring for a comatose child with multiple injuries. Providing stool softeners or laxatives as ordered, 4 (Intracranial bleeding may occur in the subdural Jun 20, 2022 · To draw fluid from the brain tissue. d) Teach parents the signs of an increase in intracranial pressure. Question: The nurse is caring for a client an unconscious client with increased intracranial pressure. Flaccid paralysis of all extremities 2. Enhanced with AI, our expert help has broken down your problem into an easy-to-learn solution you can count on. Place What nursing intervention is appropriate when caring for an unconscious child? a. The temperature of an unconscious adolescent is 105º F (40. 93 kPa). , Apply compression stockings. During this movement, it is normal for the child's eye to move to the opposite side. INCORRECT: Pillows under the head cause flexion of the neck and increase intracranial pressure. Hypotonic fluids will increase intracranial pressure. The nurse would assess the child most carefully for what finding? A. Marked irritability may be a sign of malfunction of the shunt or infection and should be reported immediately. Mannitol does not establish a sodium and potassium balance. 5 grams per kg Jun 14, 2022 · Increased intracranial pressure (ICP) occurs when pressure is elevated inside the cranial vault, which contains three components: The brain. B. The child's mother asks, "What is going on?" Select the nurse's best response. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. 43Pa02 of 70 mm HgSa02 of 94 Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client with a traumatic head injury and suspects increased intracranial pressure (IICP). Treatment focuses on lowering increased intracranial pressure around the brain. d. is the pressure in the skull that results from the volume of three essential components: cerebrospinal fluid (CSF), intracranial blood volume and central nervous system tissue. It is a common clinical problem in neurology or neurosurgical units. The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. Which prescription will the nurse anticipate for this 2. Normal blood pressure is 92-126/55-86. The nurse assesses the client for intracranial pressure (ICP). At this time, it. Renal failure and cardiogenic shock aren't complications of IV therapy. Low-pitched cry b. Changes in vital signs. The nurse is planning care for an 8-year-old child with a concussion. The normal intracranial pressure is between 5-15 mmHg. Following a craniotomy, a client has been admitted to the neurologic intensive care unit. Document the increase in intracranial pressure. Suctioning is performed only when needed to prevent an increase in the intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? Infrequent urination is a problem associated with type I malformations. Which of the following Lesson Objective for Reye’s Syndrome. Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. Sedate the patient and administer antihistamine. an improvement in condition 3. Place a cooling blanket on the child. The nurse is caring for a patient with increased intracranial pressure (ICP). 2022) The cranial vault is often described using the Monro-Kellie doctrine - the hypothesis that the cranial vault is similar to a fixed box, where any change Study with Quizlet and memorize flashcards containing terms like What finding is a clinical manifestation of increased intracranial pressure (ICP) in children? a. Study with Quizlet and memorize flashcards containing terms like The priority nursing intervention when a child is unconscious after a fall is to: a. It requires a high index of suspicion, particularly in milder cases. Increased pressure within the cranial cavity (or skull) is caused by an increase in the volume of either the brain tissue, blood, or cerebrospinal fluid, or by the presence of another space-occupying lesion. "This type of monitoring system is complex and it is managed by skilled staff. Blurred vision, The nurse caring for a client with increased react to light. Perform neurologic assessment. The nurse should question which intervention that the orientee performs? Suctioning the oropharynx routinely Rationale: Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. For children with intracranial pressure monitoring devices in place or for those who are maintained on a barbiturate coma regimen, the nurse must have extensive knowledge regarding the proper operation of the complex equipment that is helping to a nurse is caring for a client who has a closed had injury with ICp readings ranging from 16-22 mmHg. Ask the patient to report immediately if the nose bleeds. Adduction of the arms at the shoulders 3. Amnesia C. A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she has a sudden, severe headache and vomiting. Which of the following responses by the nurse is appropriate?, A nurse is caring for a client who has an UTI & is prescribed ciprofloxacin (Cipro). apply a hypothermia blanket. Many diseases or insults can result in the loss of cerebral autoregulation Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. B) A sign of increased intracranial pressure. Hazy vision. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Hemiparesis, The nurse caring for a client with increased It requires medical care right away. The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. Mannitol is used in the treatment of increased intracranial pressure to draw fluid out of the brain, thereby reducing intracranial pressure. Normal intracranial pressure c. D: vomiting and diarrhea. ANS: A. Correct Answer: A. 2 degrees Celsius (100. A. Turn the head side to side every hour. decrease the noise level in the clients room C. The clinical manifestations and diagnosis of elevated ICP in children will be reviewed here. What should the nurse do? Select all that apply. C: pulsating anterior fontanel. Papilledema c. diplopia and blurred vision, What are quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation called? and more. What should the nurse identify as a priority goal for this client's care?, The nurse is caring for an infant who is at risk for increased intracranial pressure. increased blood pressure 2. Pupil reactivity and motor response b. C) Monitor fluid intake and output carefully to avoid fluid An appropriate nursing intervention when caring for an unconscious child would be which of the following? a. The nurse is caring for a child with increased intracranial pressure (ICP). which of the following actions should the nurse take to decrease the potential for raising the clients ICP (select all that apply) A. Encourage the client to cough and take deep breaths. The client exhibits urticaria Jun 29, 2024 · Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient with increased intracranial pressure. The healthcare provider prescribes intravenous mannitol. suction the endotracheal tube frequently B. b) Apply sterile, saline-moistened dressings to the incision daily. initiate a pain assessment. Drowsiness or lack of energy. The nurse should try to maintain a quiet, nonstimulating environment for a child with increased ICP. Study with Quizlet and memorize flashcards containing terms like After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which should the nurse do first? 1. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a traumatic brain injury. The nurse would note which of the following In a patient with increasing ICP, vomiting is a result of infratentorial lesions or direct pressure on the vagal motor centers in the floor of the fourth ventricle in the medulla. Cerebral edema The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. The nurse interprets this change in the child's posturing indicates what? 1. The nurse monitors the child's intracranial pressure and urine output because mannitol belongs to which classification of diuretics? Mar 5, 2020 · Pathologic intracranial hypertension occurs when ICP is greater than or equal to 20 mm Hg (Smith & Amin-Hanjani, 2024). Assure that the patients neck is not in a flexed position. Clinical manifestations of increased ICP in an infant include a high-pitched cry, poor feeding, setting-sun sign, and distended scalp veins. 66 kPa) and an intracranial pressure (ICP) of 22 mm Hg (2. What would the nurse calculate the CPP to be? 50 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg, A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. 3. It is an emergency. ) A. This causes increased intracranial pressure. A nurse is precepting an orientee (newly hired nurse). These vital signs show increased blood pressure with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. ly/3vMHTWUSimpleNursing memberships have 1,200+ animated videos, 900+ colorful study guides, 3,000 The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. Study with Quizlet and memorize flashcards containing terms like Which of the following signs and symptoms of increased ICP after head trauma would appear first? a. Dec 24, 2023 · b. Increased blood pressure, The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil The child experiences a prolonged tonic-clonic seizure. Ask the client if he has a headache. A 10-year-old with a severe head injury is unconscious and has coarse breath sounds, a temperature of 39° C (102. Double vision B. c. Clustering many nursing activities c. " Study with Quizlet and memorize flashcards containing terms like The nurse who has been closely monitoring a client who has been exhibiting decorticate posturing notes that the child suddenly exhibits decerbrate (extensor) posturing. Elevate the head of the bed 15 The nurse is caring for a child who has been diagnosed with a brain tumor. This increased pressure will compress the brain tissue, causing damage to the neurons and leading to neuro changes and Find step-by-step Health solutions and your answer to the following textbook question: A nursing student is caring for a child with increased intracranial pressure. The development of increased intracranial pressure (ICP) may be acute or chronic. Increased Intracranial Pressure (PDF) HH-I-35 6/85, Revised 1/ Study with Quizlet and memorize flashcards containing terms like The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The MOST appropriate nursing assessment in this case is:, The nurse is doing a A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 65 mm Hg (8. Tachycardia B. To perform the "doll's eye" reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. Monitor intercranial pressure. The mother of an unconscious child has been calling her name repeatedly and gently shaking her shoulders in an attempt to wake her up. Elevating the head of bed 30 degrees d. What is an ominous sign that often precedes death? a. Difficulties in speech or movement. The nurse notes the child’s temperature to be 104°F (40°C). The nurse should first ___ followed by ___, The nurse is planning care for a preschool-age child diagnosed with bacterial meningitis. Which additional intervention is most important for the nurse to perform?, A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Increased heart rate D. Which assessment findings are recognized as early signs of increased intracranial pressure? Select all that apply. Mannitol does not enhance excretion of serum protein, which is not an intended outcome. CORRECT: Stimulation can cause increased intracranial pressure, and maintaining a quiet environment is an appropriate action for the nurse to take. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative. C) Pays A child who has been having seizures is admitted to the hospital for diagnostic testing. fixed and dilated pupils C. , The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). Study with Quizlet and memorize flashcards containing terms like A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. a. Change the child's position infrequently to minimize the chance of increased ICP. The nurse determines that the presence of this reflex is obtained by assessing which item? 1. Although prevention of trauma to the vital organs, establishment of routes for the delivery of medications, and fulfilling the health team's needs are all important, none is the The nurse does not ask the parents to be present at all times because it is not required that they be present. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a child with severe head trauma after a car accident. 1 Vomiting 2 Headache 3 Irritability 4 Tachypnea 5 Hypotension, A 7-year-old child loses consciousness a few days after a traumatic head injury that resulted in a subdural Jun 29, 2024 · 1. The nurse notes that the child is flexing her arms and wrists while bringing her arms closer to the midline of her body. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day. Acutely elevated ICP should be suspected in children with any one of the following findings (see "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis", section on 'Acutely elevated ICP' ): Severe headache with vomiting. Alteration in pupillary response C. Increased motor response D. The nursing care of children with increased intracranial pressure is extremely complex. maintain patient on the left side with the head supported on a pillow. Which medication(s) will the nurse prepare teaching on for this client? Select all that Jun 20, 2024 · a. Elevating the head of the bed 30 degrees d. place pillows under the client's knees 4. Increased ICP is a dangerous condition. The nurse who is concerned about increased intracranial pressure in an infant should assess for: A: irritability B: photophobia. Avoid activities that cause pain or crying. The infant presents with signs of increased intracranial pressure 4. The nurse monitors hematocrit in a child who undergoes repeated subdural taps to detect blood loss from the procedure. Normal heart rate for an awake child at this age is 70-110. 2° F), a heart rate of 70 bpm, a blood pressure of 130/60 mm Hg, and an intracranial pressure (ICP) of 36 mm Hg. Apr 30, 2024 · If the patient is hemodynamically stable and shows no signs of increased intracranial pressure (ICP); opening pressure may or may not be increased; the white blood cell (WBC) count in the cerebrospinal fluid (CSF) is 8/µL or fewer. May 29, 2024 · Cerebral edema Explanation: The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. Identify the early signs and symptoms of Reye’s Syndrome, emphasizing the importance of prompt recognition for timely intervention and improved outcomes. Vomiting. encourage liberal fluid intake The nurse is caring for a child with a skull fracture who is unconscious and has severely increased intracranial pressure (ICP). administer aspirin stat. When caring for an unconscious child, an appropriate nursing intervention is to: A) Change the child's position infrequently to minimize the chance of increased intracranial pressure (ICP). elevate the head of the bed 3. keep the head of the bed flat. nz tr ny gk zq wx an ko ct aj