Nursing management of Increased Intracranial pressure Today’s topic is Nursing Management for clients with increased intracranial pressure.

Etiology of Increased ICP Too much cerebrospinal fluid (the fluid around the brain-meningitis) A tumor (benign or malignant) Bleeding into the brain (Hemorrhagic stroke or aneurysm) Swelling in the brain (encephalitis) High blood pressure http://www.uptodate.com/contents/evaluation-and-management-of- elevated-intracranial-pressure-in-adults Some neurologic conditions can cause an increase to intracranial pressure. Cerebral edema is an increase in volume of brain tissue due to increased capillary permeability (leaking of the fluid from cells into the tissue), changes in functional or structural integrity of cell membrane, or increased interstitial fluids. The effects of increased intracranial pressure is proportionate to the size of the injury and may be localized or more broad. Some of the causes can be from a head injury, diseases such as bacterial meningitis, prolonged seizure activity, stroke, and brain tumors; even benign brain tumors can be deadly due the limited amount of space for tissue swelling. The cause of increased intracranial pressure is directly related to an underlying pathology. Increased intracranial pressure cuts off blood supply to brain tissue. Depending on the extant of injury is the resulting tissue death, brain damage and functional impairment. Use this link to learn more indepth about increased intracranial pressure.

Physiology-Increased Intracranial Pressure Not a disease but secondary process from an insult to the brain Prolonged pressure above 15 mmHg (normal 5-10 mmHg) Increased intracranial pressure is not a disease but rather the fall out from an insult to the brain. In adults, the intracranial compartment is protected by the rigid skull which houses a set amount of internal fluid. Shits to accommodate extra fluid will produce neurological deficits because of the squeeze on the tissue and consequent blood supply to the involved brain tissue. Prolonged pressure above 15 mmHg is considered to be Increased intracranial pressure. Normal intracranial pressure is between 5 to 10 mm Hg. Normally, you and I can have occasional transient elevations in intracranial pressure with physiologic events like sneezing, coughing, bearing down with bowel movements and so forth. In this short term events of increases in intracranial pressure, the brain can accommodate.

Clinical Manifestations of  ICP Decreased level of consciousness (LOC) lethargy, confusion, behavior changes (irritability, agitation), restlessness Headache, vision changes (diplopia lack of peripheral vision) Nausea and vomiting Change in speech pattern (e.g., slurred speech, clear speech that doesn’t make sense) Aphasia Change in sensorimotor and motor function Pupillary changes (dilated and nonreactive or constricted and nonreactive) Cranial nerve dysfunction Ataxia Seizures Severe hypertension Abnormal posturing Regardless of the cause of increased intracranial pressure, increased intracranial pressure manifests signs and symptoms based on the location and extent of tissue involvement. The earliest sign of increased intracranial pressure is a change in level of consciousness. Clients can complain of headache, vision changes, nausea and vomiting. Speech and facial muscle innervation can be impaired. Pupillary changes can occur in particular dilated or constricted pupils that are nonreactive to light. Change in motor or sensory function. cranial nerve changes, ataxia, seizure activity, hypertension, and abnormal posturing.

Cushing’s Triad 1. Hypertension (Systolic BP) 2. Widened Pulse Pressure 3. Bradycardia (170/50….180/40….200/20) Cushing's triad is is a response to increased intracranial pressure which includes 3 prominent signs of imminent deterioration. Increased systolic pressure while the diastolic stays the same, widening pulse pressure and bradycardia.

Posturing with  ICP Decorticate posturing Decerebrate posturing Lesions that interrupt the corticospinal pathways Decerebrate posturing dysfunction in the brainstem Posturing can occur with increased intracranial pressure. Decorticate posturing is characterized with planter flexion, knee extension, arm and hand flexion indicating pressure is interrupts the corticospinal pathways. Decerebrate posturing is characterized by plantar flexion, knee extension, hand flexion, and arm pronation indicating brainstem herniation. I can distinguish the difference between the two postures by associating decorticate posturing with “courting” someone because I visualize the arms and hands brought to the core of the body.

Assessment 2 types of neurological assessment Rapid neuro exam Glascow Coma Scale, LOC, orientation, movement of arms and legs, Pupil size and reaction to light Complete neuro exam LOC (mental status), memory and attention, PERRLA, cranial nerves, motor function, sensory function, deep tendon reflexes, cerebellar function Comparing one side to the other (Left – Right) subtle changes can be found with comparsion (click) There are 2 types of neurological assessments, a rapid neurological assessment and a complete neurological exam.(click) A rapid neuro exam is based on the emergent needs and client deterioration which includes a glascow coma scale, level of consciousness, orientation, movement of arms and legs, pupil size and reaction to light. The complete neuro exam includes level of consciousness also known as a mental status exam, memory and attention, pupil check with use of PERRLA exam, cranial nerves, motor and sensory function, deep tendon relfexes and cerebellar function. (click) An important part of the neuro exam is comparing one side to the other to detect subtle changes in neurological functioning.

Assessment of Labs/Diagnostics Underlying cause and assessment will determine labs (There is not one lab test to indicate  ICP) e.g., if infection is suspected, a White Blood Cell (WBC) count would be necessary Computed tomography (CT) of the brain Magnetic Resonance Imaging (MRI) of the brain Skull and spine x-rays Cerebral angiography Positron Emission Tomography (PET) scan of the brain Electroencephalography (EEG) Lumbar puncture (spinal tap) Diagnostics and lab work is directed at identifying and treating the underlying cause of increased intracranial pressure. There isn’t one lab test to indicate increased intracranial pressure. Serum osmolality like sodium, chloride, bicarbonate, proteins, and glucose monitors hydration status. and ABGs measure pH, oxygen, and carbon dioxide. Hydrogen ions and carbon dioxide are vasodilators that can increase ICP. CT and/or MRI scanning is generally the first tests. Other test can include skull and spine x-rays, cerebral angiography that looks at cerebral vessels, PET scan can be helpful in understanding the functioning of the brain, specifically glucose and oxygen metabolism and cerebral blood flow. An Electroencephalography (EEG) looks at the electrical activity of the brain. In general, a lumbar puncture is not performed because of the risk of brain herniation caused by the release of pressure. As you study, it is important to research, what nursing assessment would be important before sending patients to some of this tests. In particular some diagnostics require stopping medications, checking lab values, etc.

Plan/Goal for  ICP Adequate cerebral perfusion Minimize cerebral tissue damage/death with early interventions The plan is focused on promoting adequate cerebral perfusion and minimize cerebral tissue damage.

Interventions Monitor neurologic status and vital signs Monitor respiratory status Calculate and monitor cerebral perfusion pressure Monitor central venous pressure (CVP) Raise head of the bed to 15-30 degrees or as ordered (assists venous drainage) Bowel and Bladder function Avoid neck flexion and extreme hip/knee flexion Fluid restriction Administer medications to promote a  ICP osmotic and loop diuretics, corticosteroids Administer analgesics, sedatives as needed Antibiotics as indicated http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2452989/ The nursing interventions for increased intracranial is assessing neurological status(click) every 1-2 hours and report any changes to the health care provider. Also, look at the trending in vitals signs. Because increased intracranial pressure can impact respiratory function, monitoring respiratory status is imperative. Monitor central venous pressure (CVP). An elevated CVP indicates to much fluid. (click) Increase the head of the bed by 15-30 degrees or as prescribed to facilitate cerebral venous drainage. Assess for bladder distention and bowel constipation as this can increase intracranial pressure. Increase in stimuli can increase intracranial pressure thus, dimming lights, decreasing noise is important. (click) Avoid neck flexion and extreme hip or knee flexion. (click) Maintain fluid restriction as prescribed. If a drainage catheter is inserted via ventriculosotmy, keep dressing over catheter clean and dry and monitor for CSF leakage. (click) Administer medications to decrease intracranial pressure as prescribed. Osmotic diuretics like mannitol and lasix are commonly used to decrease intracranial pressure. Corticosteriods like dexamethasone may be beneficial (click) along with analgesics and sedatives. (click) Antibiotics can be used for specific infection causes for increased intracranial pressure. Stool softeners to decrease the need for straining. Teach the client to decrease activities that increase intracranial pressure like coughing, sneezing, blowing nose, straining, pushing against the bedrails. Advise the client to maintain head in neutral head and neck alignment. For more detailed information and understanding, use the link below to enhance your learning.

Evaluation – Desired Outcomes Normal ICP (5-10 mmHg) is maintained Ischemia is minimized Vital signs are stabilized Client returns to baseline functioning The overall goals for clients experiencing increased intracranial pressure is management of symptoms, provide comfort, provide therapies geared to bring intracranial pressure into normal pressures, minimize cerebral tissue ischemia, and ultimately, the client will return to baseline of functioning.

References Rangel-Castillo, L, Gopinath, S., & Robertson, C.S. (2009). Management of intracranial hypertension. Neurologic Clinics, 26(2), 521-541. Ignatavicius, D. D. & Workman, M. L. (2010). Medical- surgical nursing: patient-centered collaborative care (6th ed.). St. Louis, MO: Saunders Elsevier. Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., & Bucher, L. (2014). Medical-surgical nursing: Assessment & management of client problems (9th ed.). St. Louis, MO: Mosby Hogan, M., Dentlinger, N.C., & Ramdin, V. (2014). Medical- surgical: nursing pearson nursing reviews and rationales (3rd ed.). Boston, MA: Pearson. This concludes the presentation on nursing management of clients with increased intracranial pressure.