Medical Surgical Increased ICP #4
The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes will signal increased intracranial pressure?
- Rapid, shallow respirations.
This answer is not correct because increased ICP causes slow and irregular respirations due to Cushing’s reflex. Cushing’s reflex is a physiological and neurological response to increasing ICP that results in bradycardia, irregular respirations, and abnormal changes in blood pressure.
- Nasal flaring.
This answer is not correct because nasal flaring is a sign of respiratory distress. Although there are slow and irregular respirations associated with Cushing’s reflex, nasal flaring is not specifically associated with increased ICP. Generally nasal flaring is associated with acute respiratory distress, asthma, COPD, or other acute respiratory distress diseases.
- Slow, irregular respirations.
This answer is correct because respiratory changes associated with increased intracranial pressure are the result of deterioration of neural control of respirations, which is controlled by the brain stem. Deterioration and pressure produce irregular respiratory patterns. There is reduced perfusion to the brain from the swelling.
- Sudden increase in respiratory secretions.
This answer is not correct because increased intracranial pressure has no effect on respiratory secretions. Usually increased secretions from the respiratory tract come from infection or aspiration.
Increased intracranial pressure (ICP) is when the pressure inside the head increases, usually from a head injury. Symptoms include mental status change, bradycardia, irregular respirations, and high blood pressure with wide pulse pressure.
Increased intracranial pressure (ICP) is a serious condition. It occurs when the pressure inside the head increases, usually from a head injury or brain bleed. Symptoms include mental status change, bradycardia, irregular respirations, and high blood pressure with wide pulse pressure. Monitoring vital signs in the client with ICP is key. These changes indicate increasing ICP and the nurse will be able to notify the provider to begin treatment. A sudden increase in pressure, or if left untreated, can lead to further brain injury, seizure, coma, stroke or death. By knowing the symptoms of increased ICP, the nurse will be able to detect rising pressure in the client’s skull and be able to intervene to potentially save the client’s life.
Test Taking Tip
Understand Cushing’s reflex and its effect on heart rate, blood pressure, and respirations. Remember the Cushing’s triad!