Increased Intracranial Pressure (ICP)

Symptoms of ICP

-Headache -Increase BP -Confusion -Shallow Breathing -Nausea

DANGER. B.c death of neurons

>20 mm HG = dangerous or not dangerous

True

As ICP increases, cerebral perfusion decreases? T or F

Diagnostic Studies

CT Scan/ MRI/ PET EEG Cerebral angiogrpahy ICP and brain tissue oxygenation measurment NO lumbar puncture ABS Blood studies

Check Cranial nerves by eye movements

Check Eye movements: Oculocephalic relflex (doll's eyes reflex) Oculovestibular (Caloric Stimulation

Early signs of ICP

Clinical Manifestation: Early -Change in LOC (subtle changes first progressing to coma) ex: Short attention span; disoriented to time, then to person/place -Speech slows or slurred -Slow to respond to verbal commands -Lethargy, restless, confusion

Late manifestations

Clinical Manifestations: Late Flattening of affect - stupor to coma Change in vital signs Also: Decorticate or Decerebrate (more serious damage)

Nursing conisderations

Decrease environmental stimulus Avoid use of restrains, flexion of hip, sneezing, no blow of nose, attention of bowel/bladder, isometric exercises limit use of suctioning, space interventions

1. The increase in skull size 2. The extension of the cranial veins 3. The bulging of the Fontanelle 4. Loss of memory and attention

How do I know if the intracranial pressure is increased?

Glasgow Coma Scale of less than or equal to 8 Abnormal CT scans or MRI

How do you measure ICP

Cushings Triad (Refers to a set of signs associated with ICP)

Hypertension (Increase systolic) BP Bradycardia Widened pulse pressure, Apnea (breathing repeatedly starts and stops)

Nurse Therapy

Maintain airway & oxygenation ICP within normal limits reduce edema reduce CSF Maintain adequate perfusion to the brain

Correct Answer: C Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective.

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should a. monitor oxygen saturation. b. check arterial blood gases (ABGs). c. monitor intracranial pressure (ICP). d. assess patient breath sounds.

TREATMENT OD: Mannitol Inotropic Drugs: Dobutamine and Norepinephrine Steriods: Dexamethasone Phenobarbital Thiopental Propofol

Osmotic Diuretic: Inotropic Drugs: IVFL: Isotonic solutions (IV 0.9 NaCL) Steriods Barbiturate: (To induce coma to reduce cerebral metabolism)

Vomiting Headache Pupil Changes ( Sluggish to fixed and dilated), unequal, papiledema Irregular thermoregulation

Other manifestations of IICP Y or N: Vomiting? Y or N: Headache? Y or N: Pupil changes Y or N: Irregular thermoregulation

YES; to enhance drainage of jugular veins

Should HOB be elevated (Neutral position) (midline)

YES, also may restrict fluids

Should you monitor fluid, intake and output?

Check Motor Strength/ vital signs

Squeeze hands Pronator drift test Raise food of bed or bend knees

Stage 1

Stages of Increase ICP Total Compensation

Stage 2

Stages of Increased ICP Decrease compensation, risk for increase ICP

Stage 4

Stages of Increased ICP Herniation imminent-death

Stage 3

Stages of increased ICP Failing compensation, clinical manifestations of increase ICP (Cushing's triad)

True

T or F? Symptoms of increased ICP are oppoisite of shock?

True

True or False? Prolonged, elevation of pressure in cranium leads to hypoxia brain tissue w/ permanent brain damage

brain herniation via foramen of mono

What happens if edema in the brain goes untreated

Check Motor response

spontaneous or to pain

Monro-Kellie Doctrine

three components exist in equilibrium to maintain normal intracranial pressure, the brain tissue, the blood, and the cerebrospinal fluid

3. Types of cerebral edema

1. Vasogenic 2. Cytotoxic 3. Interstitial

Skulls 3 components

1.Brain tissue 2.Blood 3.Cerebrospinal fluid (CSF)

Primary Injury

Hypoxia, ischemia, hypotension, edema, increase ICP

Monro-Kellie doctrine/hypothesis

If one component increases, another must decrease to maintain ICP

10-15

Normal ICP

B. elevate the head of the bed to 30 degrees

The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient on the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position

Correct Answer: C Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

Correct Answer: B Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?a. Administer acetaminophen (Tylenol) 650 mg orally. b. Administer 5% hypertonic saline intravenously. c. Draw blood for arterial blood gases (ABGs). d. Send patient to radiology for computed tomography (CT) of the head.

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

Traumatic head Injury Tumors or abscess Hemorrhagic Stroke Ischemic Stroke Prolongs hypoxia for whatever reason Increase CDF Pressure Ruptured aneurysm Meningitis, Encephalitis

What leads to increase ICP?

Ventriculostomy (Catheter inserted into lateral ventricle) Infection: GREATEST RISK

What procedure do you do to measure ICP

Correct Answer: C Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light.