ICP, TBI, TIA

Increased Intracranial Pressure (ICP)

Definition of Increased Intracranial Pressure

• Increased Intracranial Pressure refers to the pressure within the cranial cavity, which houses the brain, blood, and cerebrospinal fluid (CSF).
• The skull acts as a closed box; thus, if one component increases, the others must decrease to maintain normal pressure levels. If this balance is disrupted, it may lead to elevated pressure that can compress brain tissue, potentially causing:
  • Decreased Level of Consciousness (LOC)
  • Brain damage
  • Death

Causes of Increased ICP

• Infection
• Increased Cerebrospinal Fluid (CSF): Excessive production of CSF or obstruction in flow.
• Head injury or trauma: Any significant blow or jolt to the head can cause changes in ICP.
• Brain tumor or bleeding: The growth of tumors or bleeding within the cranial cavity can elevate pressure.
• Stroke: Can lead to localized swelling or blood accumulation, affecting ICP levels.

Signs & Symptoms of Increased ICP

• Decorticate and Decerebrate Posturing: Abnormal postures that can indicate severe brain injury.
• Cushing's Triad (a late sign):
  • Increased Systolic Blood Pressure
  • Decreased Heart Rate
  • Irregular Respirations
• Early Indicators:
  • Decreased level of consciousness
  • Headache
  • Vomiting (without preceding nausea)
  • Blurred vision
  • Unequal pupils
  • Rising temperatures

Nursing Interventions for Increased ICP

• Positioning: Elevate the Head of Bed (HOB) to 30° to aid venous drainage.
• Alignment: Maintain alignment of the neck; discourage bending or twisting.
• Minimal Stimulation: Keep the environment calm; limit activities such as suctioning and coughing that can increase ICP.
• Monitoring: Closely monitor the neurological status of the patient.

Catheterization for ICP Measurement

• Catheter placement is performed into the ventricle to monitor CSF drainage effectively. Components include:
  • Syringe and Three-way stopcock for controlled drainage.
  • Transducer for measuring pressure.

Traumatic Brain Injury (TBI)

Definition

• Traumatic Brain Injury results from a blow or jolt to the head, causing the brain to move or shake inside the skull. This may lead to temporary changes in brain function.

Common Causes

• **Motor Vehicle Collisions (MVC)
• Falls**
• Assaults
• Sports-related injuries

Types of TBI

• Closed (non-penetrating): The brain moves within an intact skull, potentially leading to bruising and tearing (e.g., whiplash, falls).
• Open (penetrating): An object breaks through the skull and enters the brain (e.g., gunshot wound).
• Acceleration: A moving object hits a stationary head (e.g., hit with a baseball bat).
• Deceleration: The moving head impacts a stationary object (e.g., falling and hitting the floor).
• Acceleration-Deceleration: A combination of both (e.g., soccer-related injuries where the head strikes the ground).
• Rotational: Twisting of the brain within the skull leads to shearing and tearing brain tissue (e.g., side-impact car crashes).

Types of TBI and Their Descriptions

• Concussion (mild):

  • Symptoms include brief loss of consciousness, headache, dizziness, nausea/vomiting (N/V), and memory loss surrounding the event.
  • Not detectable in CT or MRI scans.

• Contusion (bruised):

  • Characterized by bleeding and swelling in brain tissue, symptoms depend on the injured part of the brain might include:
  • Decreased LOC
  • Abnormal pupils
  • Motor changes (e.g., brainstem contusion)

• Hematoma (bleed):

  • Subdural Hematoma: Venous bleeding, can be classified into:
  • Acute: Symptoms appear within 24 hours, manifest as one-sided paralysis, extraocular movement weakness, pupil dilation.
  • Chronic: Develops over weeks to months, presenting as forgetfulness, lethargy, irritability, headache.
  • Epidural Hematoma: Associated with arterial bleeding that requires immediate surgery, often linked to skull fractures.

Diagnostic Tests for TBI

• CT Scan: Useful for rapid assessment.
• MRI: Employed later to identify damage to brain tissues.
• Neuropsychological Testing: Evaluates cognitive functions such as memory, judgment, learning, and concentration.

Common Symptoms of TBI

• Headache
• Dizziness
• Confusion, feeling foggy
• Nausea or vomiting
• Sensitivity to light or noise
• Short-term memory loss

Treatment for TBI

• Barbiturate Coma: To manage ICP.
• Maintain normal temperature and blood pressure (BP).
• CSF Drainage: Alleviate ICP.
• Mannitol: An osmotic diuretic to reduce cerebral swelling.
• Mechanical Hyperventilation: Helps decrease ICP.

Nursing Treatment and Education

• Encourage rest for both the brain and body.
• Monitor for any worsening symptoms.
• Advise against sedatives and alcohol consumption.
• Educate family on signs of increased ICP and the importance of abstaining from sports/screens until cleared.
• Monitor ICP regularly for prompt recognition of changes.

Complications Following TBI

• Brain Herniation
• Labile Vital Signs (unstable)
• Diabetes Insipidus
• Post-Concussion Symptoms / PTSD
• Acute Hydrocephalus
• Cognitive and Personality Changes

Brain Attack / Stroke

Definition

• A stroke occurs when blood flow to an area of the brain is disrupted, leading to cell death. It is critical for early recognition to improve outcomes.

Types of Stroke

• Transient Ischemic Attack (TIA):
  • Defined as a temporary blockage of blood flow to the brain; symptoms can last from minutes to a few hours and usually resolve completely, but it serves as a critical warning sign.

Causes and Risk Factors for Stroke

• Hypertension
• Diabetes Mellitus
• Atrial Fibrillation: an irregular heartbeat that increases risk of stroke.
• Hyperlipidemia/High Cholesterol
• Smoking
• Atherosclerosis: build-up of fats in the arteries.
• Obesity and Sedentary Lifestyle
• Age: Increasing age is a significant risk factor.
• Gender, Family History: Non-modifiable risk factors that can relate to genetic predisposition.

Classification of Stroke

• Ischemic Stroke: Caused by blockage of blood flow, which can be thrombotic (clot formation in brain artery) or embolic (clot traveling to brain from heart).
• Hemorrhagic Stroke: Results from rupture of blood vessels, causing pressure on brain (subarachnoid or intracerebral hemorrhage).

Symptoms of Stroke (Recognized by the acronym B.E.F.A.S.T.)

• Balance: Loss of balance, coordination.
• Eyes: Sudden vision problems in one or both eyes.
• Face: Asymmetry or drooping on one side of the face.
• Arms: Weakness or numbness, inability to raise both arms.
• Speech: Confusion or trouble speaking.
• Time: Important to call emergency services immediately if any symptoms are present.

Stroke Lateralization Symptoms

• Left Hemisphere Stroke: Often affects language and logic.
• Right Hemisphere Stroke: Can present with reckless behavior or impulsivity.

Nursing Interventions in Acute Care for Stroke

• Adhere to the ABC’s (Airway, Breathing, Circulation) protocols.
• Ensure oxygen saturation is maintained above 94%.
• Monitor Level of Consciousness (LOC), vital signs, and heart rhythm.
• Dysphagia Screening: Prevent aspiration and prepare for necessary imaging to determine stroke type.

Medications for Stroke

Ongoing Nursing Interventions for Stroke Care

• Prevent complications such as Deep Vein Thrombosis (DVT), pneumonia, and pressure injuries.
• Incorporate therapy sessions (Physical Therapy, Occupational Therapy, Speech Therapy).
• Control blood pressure and blood sugar to minimize further brain damage.
• Continuous medication management, including antiplatelets, anticoagulants, thrombolytics, and statins.

Long Term Effects of Stroke

• Impaired motor function and sensation.
• Difficulty with swallowing.
• Bowel and bladder function issues.
• Aphasia (difficulty in language comprehension and communication).
• Pseudobulbar Affect (PBA): Episodes of uncontrolled laughing or crying.
• Impaired judgement and safety risks.
• Unilateral neglect: Inattention to one side of the body.

Surgical Interventions for Stroke Prevention

• Carotid Endarterectomy: Procedure to remove blockage in the carotid artery to prevent stroke occurrence.
• Carotid Stenting: A balloon and stent are used to open narrowed arteries, with the goal to restore blood flow and prevent future strokes.