Adult Health - ICP 9.2

ICP Normal Range

5-15

MAP normal range

70-100

CPP normal range

60-100

<50 = ischemia

CPP equation

MAP - ICP = CPP

5 Factors that affect ICP

Blood gases (CO2)

Posture

Temperature

Intraabdominal & intrathoracic pressures

Arterial & venous pressures

CO2 affect on ICP

High CO2 = High ICP

Lumbar puncture

Contraindicated if ICP is high

Ventriculostomy

Gold standard for measuring ICP

Ventriculostomy NC

Increased Risk of Infection

Sterile procedure

Ventriculostomy Leveling

Stop cock needs to be levels to the tragus of the ear

Basilar Skull Fracture Triad

Battles sign (retroauricular ecchymosis)

Racoon's sign

Hemotympanum

First NI for drainage from nose/ear

Test for glucose

Cushing's Triad for high ICP

1. High SBP

2. Low HR

3. Low RR

ICP risks

Brainstem herniation

DI

Mannitol

osmotic diuretic

reduces intracellular volume

Mannitol NC

hypernatremia risk

Mannitol Indications

High ICP

nonreactive dilated pupils bilaterally

Brainstem issue

Slow drooped/closure of eyelid

cranial nerve 3

Reactive Unilateral Pupil Dilation

Increasing ICP

Nonreactive unilateral pupil dilation with altered LOC

Increased ICP

ICP HOB

Between 15 and 30 degrees

NI for sudden decline in LOC

Hypoxia

Hypoglycemia

ICP Nursing Assessment

1. ABCs

2. LOC - GCS

3. Herniation: pupils & motor exam

Bacterial Meningitis

Droplet precautions for 24 hours after effective abx therapy

Common sign is nuchal rigidity (neck stiffness)

Kernig's sign

Hip flexed to 90 degrees, knee cannot be fully extended without pain - hamstring tightness

Sign of nuchal rigidity

Brudzinski's neck sign

Passive flexion of neck causes flexion of both legs and thighs

Signs of nuchal rigidity

NG NC for Skulls Fractures

No NG tube for patients with any kind of skull fracture

Meningitis s/s

In CSF:

- Low glucose

- Elevated WBC

- elevated ICP

- cloudy CSF

Encephalitis s/s

normal or elevated ICP

Elevated WBC

Normal Glucose

Clear CSF

Brain Abscess s/s

High ICP

High WBC

Low/absent glucose in CSF

Clear CSF

Propofol/Diprivan

Decreases ICP and cerebral O2 requirements

Midazolam/Versed

decrease agitation & hyperactivity caused by high ICP

Ranitidine/Zantac

H2 receptor antagonists used to prevent stress ulcers & GI bleeding

Phenytoin/Dilantin

Prevent seizures caused by high ICP

Emergency Procedure for high ICP

Emergency Burr Hole