N251 - ICP

MAP calculation

(2DIA + SYS) / 3 = MAP

4 early s/s of increased ICP

1. *↓ LOC* (1st) 2. Behavioral changes (irritability/agitation) 3. *Constant* HA 4. N/V

2 things to closely monitor for patient with ICP issues (other than v.s.)

1. Airway 2. Urine output (SIADH & DI = complications)

3 late medical treatments for increased ICP

1. Barbiturate coma - decreases cerebral metabolic demand and volume 2. Moderate hypothermia - decrease temp to 33 - 36 degrees Celsius 3. Surgical intervention - decompressive craniectomy

2 advantages of ventricular ICP monitoring

1. Best indicator of ICP 2. Can drain CSF

Three components within skull that affect ICP

1. Brain tissue 2. Blood 3. CSF

2 ways to drain CSF

1. Burr hole 2. External ventricular drain (EVD) aka ventriculostomy

5 s/s of SIADH

1. Decreased urine output 2. Fluid overload 3. Puffy, third spacing 4. Bounding pulses 5. Crackles 6. Hyponatremia

Cushing's triad consists of:

1. HTN + Widening pulse pressure 2. Bradycardia 3. Irregular/slow respiration (*if not vented*)

2 middle medical treatments for increased ICP

1. Hypertonic saline (pulls fluid into vasculature; *monitor Na & Cl*) e.g. 2-3% saline 2. Neuromuscular blockade (paralysis to decrease metabolic demand)

Monro - Kellie doctrine (3)

1. If volume of one increases, another must ↓ in order to keep ICP normal 2. Intracranial compensation is limited d/t inflexibility of cranial vault 3. Small changes in volume have great impact on ICP

6 nursing interventions for head injury patients to minimize & maintain normal ICP

1. Keep HOB 30 degrees, head inline, log roll only, no pillows 2. Decrease stimulation & irritants (minimal suctioning 3. Control fever (minimize metabolic demands and maintain ICP) 4. Nutrition & strict glycemic control (< 110 mg/dL) 5. Prophylaxis for seizure and DVT 6. Skin care

4 components of neuro checks

1. Pupillary assessment 2. Motor & sensory ability 3. Tongue deviation 4. V.s. including pain

3 early medical treatments for increased ICP

1. Sedation 2. CSF drainage 3. Diuretics: Osmotic (mannitol) & Loop

5 ICP measuring catheters

1. Subdural 2. Subarachnoid 3. Intraparenchymal 4. Epidural 5. Ventricular

4 late findings of increased ICP

1. Worsening early symptoms 2. Small/reactive → fixed/nonreactive pupils 3. Posturing 4. Cushing's Triad (very concerning)

How do metabolic demands change with patients with increased ICP?

100% - 180% higher

An acute subdural hematoma manifests signs within ______________ hours of injury

48 hours

Normal ICP

5-15 mmHg

The patient reports falling when he his foot got "stuck" on a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication? A. Epidural hematoma B. Subdural hematoma C. Subarachnoid bleed D. Diffuse axial injury

A Epidural hematoma often results from a linear fracture crossing a major artery in the dura. The classic sign is an initial period of unconsciousness at the scene and a brief lucid interval followed by a decrease in LOC. A subdural hematoma often results from injury to the brain and veins and develops more slowly. The classic sign or symptom of subarachnoid hemorrhage is a patient describing "the worst headache of my life." Diffuse axonal injury is widespread axonal damage occurring after a traumatic brain injury

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

How are osmotic diuretics (mannitol) useful in increased ICP?

Actively pulls fluid from brain and removes via urine

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11

B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4 Total = 7

The nurse recognizes the presence of Cushing's triad in the patient with: a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP. The signs include an ↑ systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

CPP goal

Between 50 - 70 mmHg (*ideally 60 mmHg*)

A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? A. Urine output increases from 30 mL to 50 mL/hour. B. Blood pressure remains less than 150/90 mm Hg. C. The LOC improves. D. No crackles are auscultated in the lung fields.

C LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although the other options may indicate a therapeutic effect of a diuretic, they are not the main reason this drug is given.

You are alerted to a possible acute subdural hematoma in the patient who A. has a linear skull fracture crossing a major artery. B. has focal symptoms of brain damage with no recollection of a head injury. C. develops decreasing LOC and a headache within 48 hours of a head injury. D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC.

C. An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression by increased intracranial pressure (ICP) and include decreasing LOC and headache.

Adequate perfusion of oxygen and a supply of nutrients (glucose) is dependent on both:

CPP & cerebral blood flow

A *systolic* BP less than ____ or a CPP less than ___ yields worse outcomes for neuro injury patients.

CPP: < 50 Sys: < 90

How does the brain self regulate to keep blood flow constant?

Can cause vasodilation and constriction to carotid arteries and veins to maintain needs.

Progression of altered respiratory pattern in late findings of ICP (3)

Cheyne-Stokes ↓ Neurogenic hyperventilation ↓ Irregular/apneic

When the RN applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as: a. decorticate posturing. b. decerebrate posturing. c. localization of pain. d. flexion withdrawal.

Correct Answer: A Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing the sternocleidomastoid muscle D. Nail bed pressure

D. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nail Bed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the RN anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

An ICP greater than ______ mmHg is considered elevated, and an ICP of ______mmHg or greater requires immediate treatment

Elevated: > 15 mmHg ICP: ≥ 20 = Immediate intervention (significantly affected perfusion to brain)

Hyper or hyponatremia for DI?

Hypernatremia

Nursing intervention for elevated temperature in increased ICP?

Ice bags, fan, cooling blanket - Tylenol won't help because the elevation related to brain thermoregulation issue, not fever

Can the brain store blood?

No

Will the brain continue to auto-regulate when ICP is increased?

No, will eventually fail

What is ICP?

Pressure exerted by the total volume from the three components within the skull

What is cerebral perfusion pressure?

Pressure needed to ensure blood flow to the brain (MAP - ICP)

Most serious type of brain herniation 3 effects

Uncal brain pushed down onto brain steam Effect: coma, bradycardia, bradypnea

Craniotomy vs craniectomy

otomy: skull bone flap removed then, replaced ectomy: flap implanted into SQ fat until it can be replaced later

How often neuro check?

q15min x 1hr; q30min x 2hrs; q hour

Pupillary changes in the late stages of ICP?

small/reactive → fixed/nonreactive