Increased Intracranial Pressure (ICP) - CM

Increased Intracranial Pressure (ICP)

ICP → A dangerous condition and can lead to brain death!!

• ICP is created by the cerebrospinal fluid (CSF) and brain tissue within the skull. \n

• The volume and pressure of these 3 components are usually in a state of equilibrium and produce the ICP. \n

• **What is normal intracranial pressure? \n \n * *5-15 mmHg \n **

• **What level of ICP requires immediate intervention? \n \n ** >20 mmHg → Needs treatment!!! \n

• **What are 3 structures inside the skulls that can alter ICP? \n **

• Brain

• Cerebrospinal fluid (CSF)

• Blood

Factors that Influence ICP:

• Body temperature (such as hyperthermia) \n
• Oxygenation status, especially CO2 & O2 levels (If pt is hypoxic) \n
• Body position (keep them 30-45 degrees position) \n
• Arterial & venous pressure \n
• Anything that increases intra-abdominal/thoracic pressure \n

1. Vomiting
2. Bearing down

• **What is Cerebral Perfusion Pressure (CPP)? \n \n ** The pressure that pushes the blood to the brain… hence influencing cerebral blood flow (CBF). \n
• **What is the normal CPP? \n \n * *60-100 mmHg \n \n ** → When CPP falls too low, the brain is not perfused, and brain tissue **DIES! \n **
• **How do we calculate the CPP? \n \n * *Using a formula: \n \n ** CPP = MAP - ICPP \n \n Ex: BP→90/42, ICP → 19 \n \n 42 (diastolic) X 2= 84 \n \n 84 + 90 (systolic) = 174 \n \n 174 / 3 = **58 is our MAP \n \n ** 58 - 19 (ICP) = **39 → CPP \n **

Pathophysiology:

How ICP is affected by CSF, brain’s blood, and tissue → These all work together to maintain cerebral perfusion pressure (CPP).

Risk Factors:

• Head trauma/injury/edema

• Conditions that can increase high CSF

• Bleeding/hemorrhage

• Hematoma

• Hydrocephalus

• Tumors in the brain

• Ischemic stroke → Edema

• Infection

• Encephalitis or meningitis

Signs & Symptoms:

• ICP = Ischemia

• Because there is a drop in cerebral perfusion pressure (CPP).

• Decreased amount of blood going to the brain tissue.

• Then the body tries to compensate and increases the systolic blood pressure, pushing more blood to the brain.

• The pressure continues to increase and is not being alleviated in hopes of increasing oxygenated blood to the brain.

• Increased SBP:

• Swelling/edema in the brain \n

• Irregular breathing and retaining CO2 (acidic) \n

• Arteries dilate (compress the venous system) \n

• Limit blood flow back to the heart → Blood hanging out in the brain = More SWELLING & INCREASED-ICP.

• Displace the brain tissue (herniate) or compression on the brain stem (HR and RR), which can lead to DEATH.

Mind Crushed!

• \n **What kind of Mental Status s/s? \n **

• Restlessness

• Confusion responding to questions

• **What kind of irregular breathing would a patient with ICP have? \n \n ** → Cheyne-stokes hyperventilation, then apnea. \n

• **What nerves are impacted by ICP? There are 2? And what are the symptoms? \n **

• Ocular motor nerve

• Optic nerve

• S&S:

• Double vision

• Swelling of the optic nerve “papilledema”

• Pupils can be dilated or big/small in size or unequal

• Abdnormal Doll’s eye “oculocephalic reflex” (Indicates if there is any damage on the brainstem)

• **What positions are possible with ICP? \n **

• Decerebate (external flex) → Bad

• Decorticate (internal flex)

• Flaccid (firm)

• **What is a late sign of ICP? \n \n ** Cushing’s Triad → Late sign. \n

• **What signs and symptoms are involved in Cushing's triad? \n **

• Increased BP (widening pulse pressure)

• Decreased HR & RR

• Babinski reflex (toes would fan out)

• Unconcious (late sign)

• Seizures

• Headache

• Emesis (vomiting) without nausea

• Deterioration of motor function

Potential Complications of the Disease:

• Seizures
• Stroke
• Brainstem herniation
• Neurological damage
• Death

Medications/Treatment:

• Avoid sedative or CNS depressants.

• Osmotic diuretics → Mannitol: Decreases the swelling.

• Hypertonic Saline (1.5% or 3%) → Decreases swelling.

• Corticosteroids → Decreases inflammation.

• **Craniectomy (**Removing portion of the skull) → Makes more room.

• Drain spinal fluid → Ventriculostomy/External Ventricular Drain (Monitors the ICP and drain off CSF).

• Catheter that is inserted in the lateral ventricle that monitors.

• Monitor for ICP greater than >20 mmHg + Report to a physician.

Nursing Implications:

Goal → Preventing further increased ICP and monitoring ICP readings while providing routine patient care.

Think of →“Pressure”

Position

• The HOB 30-45 degrees
• Keeping head midline
• No flexion near the neck or hips

Rrespiratory

• Prevent hypoxia & hypercapnia \n
• Monitor ABGs, O2, and suctioning (no more than >15 seconds) \n
• If on mechanical ventilation the PaCO2 → 30-35 \n
• Keep PEEP LOW → Positive End of Expiratory Pressure low because if too high it can increase intrathoracic pressure. \n
• **If a patient mechanically ventilated, why do the PaCO2 value ranges need to be around 30-35?? \n \n ** Keeping the carbon dioxide lower than the lower limits; causes vasoconstriction, which decreases intracranial pressure (ICP). \n

Elevated temperature

1. Prevent the patient from developing hyperthermia.

• Damage to the hypothalamus, infection, or dehydration = increases the temperature.
• Monitor temperature very closely
• Avoid → Oral and Axillary routes!

Interventions include: Antipyretics, giving cool baths, removing extra blankets, lower room temperature, and providing the patients with cool blankets.

• **What if a patient is unconscious? Which route would you take their temp? \n **

• Rectally

• Temporal

• Tempanically

• **What is an antipyretic drug? \n \n ** An antipyretic medication is a substance that reduces fever. \n

Systems to monitor

• Neuro checks

• Glasgow coma scale

• Best Score → 15

• Comatose → Less than <8

• Unresponsive → 3

Straining activities that are Avoided

• Vomiting
• Sneezing
• Coughing
• Keep environment calm
• Vasalva (bear down)
• Avoid restraints

Unconscious Pt care

• Avoid over sedating (mask early signs and symptoms of ICP)
• Lung sounds (suction as needed)
• Immobile (skin break down, nutrition at risk, renal stones (laying), constipation, risk for contractors (Passive Range Of Motion)
• Eye care (eye solution)
• GI tubes
• Blood clots (immobile)
• Treat the patient as they are conscious

Rx (prescriptions)

• Barbituates: Decrease the brain metabolism + decreases BP.

• Hypertonic Saline (1.5% or 3%) → Decreases swelling.

• Vasopressors/IV-Fluid or anti-hypertensives (low or high):

• We want systolic to be alteast >90 -<150 (no higher than 150 systolic).

• Anticonvulsants → Risk for seizures

• Mannotol - Hpyerosmotic drugs → Fluid/edema management

• Drug is considered a concentrated sugar.

• Draws water that is pooling in the brain into the blood to be excreted out through the kidneys.

• Filtered through the glomerulus (Part of that nephron that filters the blood)….

• Once it hits the renal tubules, it is NOT reabsorbed → Causes water and sodium, and chloride not to be reabsorbed; instead excreted.

• Look/Monitor for → Fluid volume overload and depletion.

• If not careful and put too much pressure on the heart leading to → Heart Failure or Pulmonary Edema.

• Lung sounds (clear or crackles) & heart sounds

• Dry mouth → Mouth care

• BP

• Fever (dehydration can increase the risk for fever)

• Renal function

• Electrolytes

• UO

• Loop Diuretics

• Corticostaroids →Decreases inflammation

Edema Management

We want to dehydration brain… very carefully → Monitor BP and renal function.

Nursing Diagnosis:

• Risk for imbalanced body temperature related to damage to the hypothalamus, dehydration, and infection
• Risk for ineffective cerebral tissue perfusion related to cerebral edema