ICP

• ICP 


  Increased cranial pressure
• Cause of ICP


  brain trauma, intracranial hemorrhage, brain tumors
• S/S of ICP


  restlessness, irritability, decreased LOC, headache, Vital sign changes are a late indication of increasing ICP. Vomiting, headache, dilated pupil on affected side, hemiparesis/hemiplegia, decorticate and then decerebrate posturing, increased bp/HR, late – fixed pupil
• TM for ICP


  burr holes - decrease pressure

  sedated, paralyzed, mechanically vented
• Nursing interventions for ICP

  Minimize suctioning, no coughing, no sneezing, avoid hip flexion, cluster care, 30 degree head elevation