In this lecture, we’ll be focusing on the five test questions about intracranial pressure (ICP) that are usually asked on major nursing tests and the NCLEX®.
Your client has a change in his or her Glasgow Coma Scale (GCS), when do you tell the doctor about it?
There are two instances wherein you have to tell the doctor about changes in the GCS of your client.
The first instance is within the first 48 hours. If there is a slight change, either good or bad, immediately inform the doctor about it. Telling the doctor within the first 48 hours of the changes, whether good or bad, is a priority regarding your client care.
For a coma client, if 48 hours have passed and the GCS is eight or less, this is the second instance that the doctor must be alerted. Usually, comatose clients have an endotracheal tube that goes inside their lungs. However, even with the presence of an endotracheal tube and you notice that your client is deteriorating after you’ve done a neurological assessment, you have to inform the doctor the condition ASAP.
Now, if the after 48 hours and the client’s GCS is getting better, there is no need to inform the doctor about it because this is an expected outcome.
When do you give an endotracheal tube in terms of your GCS?
As mentioned earlier, clients who have a GCS of anything less than eight should have an endotracheal tube. This is due to the knowledge that if the client’s GCS is below eight, his or her condition is highly critical and will probably be inside the neurology ICU.
What are the three things that you have to make sure of when positioning your client?
- You have to keep the client in a neutral position which means that there should be no neck bending, flexing, or any motion. As much as possible, keep your client at a 30-degree neutral position to facilitate cerebral drainage.
- Log roll. When moving the client, log roll is a priority. When doing a log roll, you need to have an assistant to keep the client in one straight line. One should hold the head while the other moves the body. Therefore, if you are going to clean your client, coordination is a must.
- No flexing (Matrix). As mentioned, make sure that when you are moving your client, there will be no flexing and bending of any part of the body, even the extremities.
When it comes to increased carbon dioxide (CO2) levels, what is the number that you have to watch-out-for?
Increased CO2 inside the brain will cause blood vessel dilation; which should be avoided. Decreasing the amount of circulation to the brain is another priority so as not to increase the pressure. Therefore, the number that you have to take note of when assessing for CO2 increase is anything greater than 40 mm/Hg.
Anything that is more than 45 mm/Hg is considered a hazard. In hospital settings, the CO2 is usually kept underneath the borderline to maintain an alkalosis, oxygenated state.
Do you cluster your care with your ICP clients if your client is in a coma with an endotracheal tube?
Clustering care basically means that the medical provider will do all care at specific times instead of constantly going in and bother the client. Cluster care is usually seen in pediatrics with the newborn assessment.
So, when dealing with an ICP client, you have to cluster your neurological assessment depending on the hospital policy – can either be every 15 minutes or hourly, depending on the client’s condition. However, you should not do cluster care for activities of daily living, feeding times, oral hygiene, and monitoring.
For those who wanted to check out our GCS scale lecture, we have a video via SimpleNursing.com. The lecture and video will provide everything you need to know about Glasgow Coma Scale and it even comes with a GCS dance. So check that out.
On our next lecture, we’ll be going over the GCS quiz.