Increased ICP
Normal ranges of ICP
5-15 mm Hg
What changes in vital signs might occur with increased ICP
Cushing's Triad, temperature alterations related to impact on hypothalamus
What are the earliest signs of increased ICP?
LOC, change in EEG, diplopia, blurred vision, change in VS, headache?, nausea
What fluid and electrolyte considerations are important in patients with increased ICP?
Need to create a normovolemic state is very important, and is achieved by monitoring fluid and electrolyte status and intake and output.
What are some potential causes of increased ICP?
an increase in any of the three components of the skull (blood, brain tissue, CSF), like a lesion (hematoma, abcess, contusion, tumor), cerebral edema (tumors, hydrocephalus, head injury or brain inflammation), or metabolic insult, brought about by MVA, stroke,
What should a nurse be aware of when helping to maintain an airway in a patient with increased ICP?
be alert to breathing patterns, keep patient lying on one side with frequent position changes, snoring sounds indicate obstruction and require immediate intervention, monitoring of ABG values
Why is meeting the nutritional needs of patients with increased ICP so important?
because early feeding following injury improves outcomes, patients are in a hypermetabolic and hypercatabolic state that increases need for glucose, because continued malnutrition promotes continued cerebral edema
Why is 0.9% NACl the preferred solution for administration of IVPB medication?
because if DW5 or 0.45% NACl is used, serum osmolality is lowered and increase in cerebral edema occurs
Why is increased ICP clinically significant?
because it diminishes CPP, increases risks of brain ischemia and infarction, and is associated with a poor prognosis
Why are corticosterioids like Decadron used to treat increased ICP
because they treat the vasogenic edema surrounding tumors and abscesses
How is the patient's LOC defined?
by both the behavior and the pattern of brain activity recorded in an EEG (electroencephalogram), changes in vital signs
What are some signs/symptoms of infection associated with ventriculostomy?
change in CSF color or clarity
What are some neurological changes that would happen with increased ICP?
changes in LOC, including unconsciousness
What are the later signs of increased ICP?
continued decreased LOC, systolic hypertension, widening pulse pressure, bradycardia, body temperature change, Cheyne-Stokes breathing pattern, posturing, decreased motor and sensory responses, coma
What are some changes in motor function that would be observed with increased ICP?
contralateral hemiparesis/hemaplegia depending on location and source of increased ICP. Painful stimuli-may localize to stimuli or withdraw from it, decorticate or decerebrate posturing
What occular changes might happen as a result of increased ICP?
dilation on same side of injury, sluggish or no response to light, inability to move eye upward (sunsetting), ptosis of eyelid, fixed unilaterally dilated pupil, blurred vision, diplopia, changes in extraocular eye movements.
What is the best position to put a patient in to decrease ICP?
head of bed elevated to 30 degrees
What neurological patients are corticosteroids not recommended for?
head-injured patients
What drug therapy is used for reducing metabolic activity in patients at risk for increased ICP?
high doses of barbituates, which decreases cerebral metabolism. ICP, blood flow and EEG should be monitored while they are administered
When would a patient with increased ICP be put on a ventilator?
if they have a GCS scale of less than 8 or they have altered LOC and are unable to maintain airway patency on their own
When might ICP monitoring be used?
in patients who have a risk for or have elevations of ICP
What are the major complications of uncontrolled increased ICP?
inadequate cerebral perfusion and cerebral herniation
What is the major complication associated with ventriculostomy?
infection
Can be measured in the ventricles, subarachnid space, epidural space, or brain tissue using a pressure transducer
intracranial pressure
The hydrostatic force measured in the brain CFS compartment, ie how much pressure is exerted between the balance of pressure from the three components (blood, tissue, fluid)
intracranial pressure
What is the most sensitive and reliable indicator of a patient's neurological status?
level of consciousness
What are some respiratory considerations for a patient with increased ICP?
maintenance of a patent airway (tongue, secretions), prevent hypoxia and hypercapnia, elevation of the head of the bed to 30 degrees, suctioning and couging, suctioning kept to a minimum and less than 10 seconds in duration
What medications might be used to help treat increased ICP?
mannitol (osmotic diuretic), antiseizure drugs (ie Dilantin), Corticosteroids (dexamethasone/Decadron) Histamine H2 receptor agonists (Tagamet/cimetidine) or proton pump inhibitors to prevent GI ulcers and bleeding, hypertonic saline to raise osmolarity of extracellular fluid in the brain
Are all increases in ICP considered dangerous?
no, the brain has some limited ability to adapt to changes
What activities increase ICP and what can be done to mitigate these increases?
pain, anxiety, fear from initial injury, noxious stimuli increase BP and ICP. Sedatives, analgesics, paralytics are used. Valsalva, coughing, sneezing, hypoxemia and arousal from sleep can also increase ICP, rapid changes in movements,
How does Mannitol act to decrease ICP?
plasma expansion and osmotic effect, acts as an osmotic diuretic
intracranial pressure is measured using what?
pressure transducer, transcranial doppler, CT, MRI, EEG, angiograms, ventriculostomy, ICP measurement, brain tissue oxygenation measurement (LICOX catheter), evoked potential studies, PET (for cause)
What are some measures to help prevent infection with a ventriculostomy?
prophylactic systemic antibiotics, good care of the skin around insertion site, routine diagnostic testing of CSF
What electrolyte levels are particularly important to monitor in a patient with increased ICP?
serum glucose, sodium, potassium, magnesium and osmolality
Which preserves blood flow to the brain better, slowly developing increases in pressure, like a tumor, or sudden increases in pressure, like a primary injury?
slowly developing increases
What is Cushing's Triad?
systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations
What kinds of patients should ICP be monitored in for sure?
those with GCS of 8 or less and an abnormal CT/MRI
How are the nutritional needs of patients with increased ICP met?
though oral intake, enteral feedings, parenteral nutrition, monitoring of F&E status, I&O important to ensure normovolemic state
Why is it important to monitor urinary output in patients with increased ICP?
to monitor for diabetes insipidus or SIADH, which could cause sodium imbalances
Why might hypertonic saline be used to treat increased ICP?
to raise the osmolarity of the extracellular fluid in the brain, decreasing cerebral water content
How is fluid and electrolyte monitored in patients at risk for increased ICP?
urine output, insensible fluid loss, serum and urine osmolality, serum electrolytes
How should temperature be managed in patients with increased ICP?
use of antipyretics, cool packs, blankets, ice packs or intravascular cooling devices while avoiding shivering and shaking, which would increase metabolic workload on the brain
What mechanisms help regulate ICP?
vasoconstriction/dilation, distention/compression of brain tissue, fluid levels
What is the "gold standard" for monitoring ICP?
ventriculostomy, because it directly measures the pressure in the ventricles, facilitates removal/sampling of CSF, and allows for intracranial drug administration
What GI complication might indicate increased ICP?
vomiting, as a non-specific sign (unexpected vomiting)
What metabolic demands should be carefully monitored in patients with increased ICP?
watch for fever, shivering, pain, seizures. Reducing metabolic demands can lower ICP in at risk patients.
What are some important nursing considerations when administering corticosteroids?
watch for hyperglycemia, increased incidence of infections, and GI bleeding; monitor fluid intake and sodium and glucose levels regularly (q 6 hours), pts should also be getting antacids or histamine H2 receptor blockers or proton pump inhibitors to prevent GI ulcers and bleeding