Icp

[TeresaB930, BSN, RN]

I was doing admits today at a SNF, and admitted a woman whose admitting dx is intracerebral bleed. I was working with another nurse and wrote a treatment for HOB up 30 degrees at all times, (due to increased risk of ICP related to intracerebral hemmorhage.) She disagreed with me, and didn't think this would be a risk.

Could have sworn I learned that, but would appreciate any feedback....

Thank you.

[CyndieRN2007]

Does she have any signs of increased ICP? If so, then I would implement that action.

[TeresaB930, BSN, RN]

She seemed to become restless when I laid the bed down to roll her and inspect her backside. She kept rolling back over on her back, and flipping her leg back and forth.

I've had my LPN for just over a year, but only work part time, while continuing on to get my RN. I don't see alot of acute patients.

[morte, LPN, LVN]

if she is more comfortable with the head up, would "hob at 45" for patient comfort " work?

[cmo421]

HOB elevated 30 degrees is always a good thing when in doubt. First,she is post ICH,so chances of increase ICP are small. But ,aspiration and other indicators, advocate for elevation of the bed when at rest.

[RN1980]

if the the patient was admitted with dx of a bleed of course she is at risk for icp, you were right raise the head of that bed. and review any info you have on ways to manage and prevent a increase of icp. also look at literature for ways to spot if the patient is having increased icp "cushing response". good job teresa....

[Christie RN2006]

All of our neuro patients HOBs have to be between 30-45 degrees. All of our vent, difficulty breathing and tube feed patients have to have their HOB at 30 degrees also. It decreases ICP, helps with breathing and reduces the risk of aspiration.

[MAISY, RN-ER, BSN, RN]

When in doubt always HOB up....always do what you think is right. Go with your gut...but, it's always a good idea to have basic reference books when you work-I carry them all the time.

There is no fault in checking-your patients will thank you.

Maisy;)

[cmo421]

if the the patient was admitted with dx of a bleed of course she is at risk for icp, you were right raise the head of that bed. and review any info you have on ways to manage and prevent a increase of icp. also look at literature for ways to spot if the patient is having increased icp "cushing response". good job teresa....

Alsolutely right. But the pt she is talking about is in a long term care facility, I am surmising. Increase ICP should be part of every assessment and HOB should be up. Risk is much lower at this point of recovery or she would not have been sent out of acute care. (hopefully) Reading up on pts diagnosis' is always helpful and will only better your assessment skills. Remember, always err on the side of precaution, it will cya. The nurses that have been there awhile are more comfortable in their shoes,so less apt to be as cautious,not always a good thing.

Your obvious maturing critical thinking skills will go with you and benifit u in school and ur future profession.

[Daytonite, BSN, RN]

(page 325, Signs and Symptoms: A 2-in-1 Reference for Nurses under the listing for "headache")

"In some patients, intracerebral hemorrhage produces a severe generalized headache. Signs and symptoms vary with the size and location of the hemorrhage. A large hemorrhage may produce a rapid, steady decrease in LOC, perhaps resulting in coma. Other common findings include hemiplegia, hemiparesis, abnormal pupil size and response, aphasia, dizziness, nausea, vomiting, seizures, decreased sensation, irregular respirations, positive Babinski's reflex, decorticate or decerebrate posture, and increased blood pressure."

(page 400, Signs and Symptoms: A 2-in-1 Reference for Nurses under the listing for "decreased level of consciousness")

"Intracerebral hemorrhage, a life-threatening disorder, produces a rapid, steady loss of consciousness within hours, commonly accompanied by severe headache, dizziness, nausea, and vomiting. Associated signs and symptoms vary and may include increased blood pressure, irregular respirations, Babinski's reflex, seizures, aphasia, decreased sensations, hemiplegia, decorticate or decerebrate posture, and dilated pupils."

The patient should be evaluated by the Glasgow Coma Scale on a regular ongoing basis. I would say that keeping the HOB elevated at all times is an arbitrary thing and only absolutely necessary if the patient starts to show signs of a decreasing level of consciousness. You can certainly keep his head elevated while you are on duty and caring for him if you like. I don't see that it would cause any harm. However, for care planning purposes I would write a nursing intervention to

observe

this patient for the signs and symptoms that are listed in the above information. The minute this patient shows any evidence of drowsiness, somnolence or stupor I would get his head elevated. You might amend your order to say:

HOB up 30 degrees at all times if patient becomes drowsy, somnolent, stuporous or has a Glasgow Coma Scale score of 7 or below and cannot be aroused

.

The emergency actions listed for decreased level of consciousness are

• keep the airway open
  
  
• elevate the head of the bed 30 degrees
  
  
• turn the head to the side if there is no spinal injury
  
  
• prepare to suction airway and support breathing