Intracranial pressure

Test 4 - sem 3

What is in the brain?

Brain tissue, blood cerebrospinal fluid (CSF)

*When one component increases, the others must decrease to maintain equilibrium 

Risk factors for increased ICP

Head injury

Brain tumors

Hydrocephalus

Intracranial hemorrhage

Toxic/viral encephalopathies 

Early signs of increased ICP

Decreased LOC

Altered mental status

Headache

Late signs of increased ICP

Unilateral fixed and dilated pupil

• ipsilateral (same side) to cranial nerve compression

• motor paresis contralateral (opposite side) to herniation

Cushing’s triad

• widened pulse pressure (space between diastolic and systolic)

• bradycardia

• irregular resp pattern

How is increased ICP detected?

Performing serial neurological assessments

• elements of wakefulness

• arousal

• cranial nerve

• motor function

***Most sensitive indicator = decrease in LOC

Diagnostics for increased ICP

X-ray

CT

MRI

EEG

Serum osmolality

Serum sodium

Ultrasound

Lumbar puncture (last resort) 

Factors the influence ICP

Intra-abdominal & intra-thoracic pressure

• coughing

• sneezing

• Valsalva maneuver

Temperature

• hypothermia – decreased metabolism

• hyperthermia – increased metabolism

Arterial and venous pressure

• autoregulation 

Blood gasses

• elevated CO2 

Position

• turning

• sitting up/laying down

Normal ICP

Infant: 1-5.6 mm/Hg
Child: 3-7 mm/Hg
Adult: < 15 mm/Hg

Intraventricular Catheter - Ventriculostomy/external ventricular drain

Most common

Increased risk for infection

Can drain CSF

*Can be done at the bedside

Intraparenchymal sensor/probe

Micro-strain gauge attached to tip of catheter

Fiberoptic technology

Does not drain CSF

Subarachnoid Bolt (SAB)

Bolt or screw connected to a fluid filled transducer system

Inability to drain CSF

Inaccuracy of Measurement due to drift

Nursing management for ICP procedures

Keep dressing over catheter dry and change as prescribed

Monitor insertion site for CSF leakage, drainage or infection

​Maintain proper device height

Monitor for manifestations of infection

Use strict aseptic technique when

ICP management - Mannitol

Drug class: osmotic diuretic

Route: IV

Mechanism of action: increase plasma osmolality → draws water out of swollen brain tissue

• diuresis → increase urine output

Effect on ICP: rapid reduction; lasts 4-6 hours; rebound risk if BBB disrupted

Effect on circulation: osmotic diuresis → decrease intravascular volume; may decrease BP and CPP

Best use case: normotensive/hypertensive with good renal function

Risks/side effects: hypotension, hypovolemia, renal injury, electrolyte loss, rebound cerebral edema

Contraindications: hypotension, renal failure, disrupted BBB

ICP management - 3% Hypertonic Saline (NaCl)

Drug class: hyperosmolar crystalloid

Route: IV

Mechanism of action: increase serum Na+ (increase osmolality) draws water out of the brain tissue and into intravascular space

• vascular expansion → fluid comes out of the brain and goes back into the system/vessels

Effect on ICP: rapid reduction; more sustained effect

Effect on circulation: expands intravascular volume; increase BP and CPP

Best use case: hypotensive, hypovolemic, or renal-impaired patients

Risks/side effects: hypernatremia, fluid overload, pulmonary edema, osmotic demyelination

Contraindications: severe hypernatremia, heart failure, uncontrolled fluid overload

ICP management - surgical

hemicraniectomy and durotomy

hematoma evacuation

ICP management - sedative use

MSO4

Versed (midazolam)

Fentanyl (sublimaze)

Propofol (diprivan)

ICP management - physical interventions

↑HOB at least 30° (45-90)

Neck in neutral position

Minimized hip flexion 

ICP management - hyperventilation

↑ RR → ↓ CO2 and cerebral blood vessel constriction

Maintain CO2 of 30 – 35 mmHG with hyperventilation 

ICP management - external CSF drainage

Ventriculostomy

Nursing inventions for ICP

Assessment:

• Serial neurological assessments every 1 to 2 hours in the critical phase, decreasing in frequency as the risk of cerebral edema and secondary brain injury decreases

• Vital signs and oxygen saturation (SpO₂) every 1 to 2 hours

• Temperature every 1 to 2 hours

• Intracranial pressure and CPP every 1 to 2 hours or more frequently if the patient is experiencing an increase in ICP and/or a deterioration of neurological assessment

• Cardiac rhythm; serum markers of myocardial injury (creatinine kinase, creatinine kinase specific to cardiac muscle, and troponin)

• Intake and output every 1 to 2 hours

• Serum sodium and/or serum osmolality

• Serum electrolytes

• Blood urea nitrogen (BUN) and creatinine

• Arterial blood gas samples

• End-tidal carbon dioxide (EtCO₂) continuously to guide hyperventilation therapy during treatment of increased ICP

Actions: 

• The head of the bed should be maintained at greater than 30 degrees, with the patient’s head in midline. Avoid sharp hip flexion.

• Avoid placing the patient in a position that allows pressure directly on the operative side after craniectomy.

• Perform endotracheal suction only as necessary; preoxygenate with 100% oxygen for 1 to 2 minutes prior to suctioning.

• Administer sedative medications as prescribed.

• Administer osmotic agents (mannitol and hypertonic saline).

• Ensure continuous drainage of CSF through the external ventricular drainage system when applicable.

• Administer antipyretics and/or implement cooling measures.

Teaching:

• Devices used during the course of treating increased ICP

• Medications used to treat increased ICP

• Complications of increased ICP

• Rationale for helmet after craniectomy

• Importance of allowing the patient to rest

What is hydrocephalus?

The build up of CSF in the brain

Congenital hydrocphalus

Present at brith

Acquired hydrocepgalus

Developed overtime

Hydrocephalus increases risk for…

Developmental disabilities​

Visual problems​    

Abnormalities in memory​

Reduced intelligence

Therapeutic management for hydrocephalus

Shunt = most common​

​Complications:​

• Infection​

• Obstruction​

• Revision with growth

Nursing assessment for hydrocephalus

Health History​

Physical Examination​

Inspection ​

Palpation​

Diagnostic tests

Nursing management for hydrocephalus

Maintain cerebral perfusion​

Prevent/recognize shunt infection and complications​

Minimize neurologic complications​

Promote growth and development​

Maintain adequate nutrition​

Support and educate child and family

What is meningitis?

The inflammation of the menages

Causes of meningitis

Bacterial infection

Viral infection

Fungal infection

Aseptic meningitis

Symptoms of meningitis

Headache

Altered mental status

Phonophobia

Fatigue

Severe muscle pain

Dislike of bright lights

N/V

Paleness

Spots/rash

Blotchy

High fever

Seizures

Stiff neck

Sleepiness or difficulty waking

Medical management for meningitis

Diagnostics: ​

• CSF exam with lumbar puncture (glucose, protein, WBC,gram stain, culture)​

• CT/MRI of head​

• Lab: urine, throat, and blood cultures; CBC​

• Cardiac testing​

• Medications:​

Broad-spectrum antibiotics, ceftriaxone, vancomycin​

Tx for 14-21 days

Nursing management for meningitis

Assessments:

• Neurologic exam​

• Vital signs (↑ temperature)​

• Fluid balance​

• Cranial nerves​

• Renal function​

• Vascular assessments

Actions:

• IV fluids​

• Antibiotic administration​

• ↓ stimuli​

• HOB at 30°​

• Pain management​

• Standard precautions

Prevention of meningitis 

Haemophilus influenzae type b (Hib) vaccine​

Pneumococcal polysaccharide vaccine (PPSV)​

Meningococcal vaccine (MCV4)