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Outline
Pathophysiology
Increased pressure within the cranial cavity (or skull) is caused by an increase in the volume of either the brain tissue, blood, or cerebrospinal fluid, or by the presence of another space-occupying lesion. This increased pressure will compress the brain tissue, causing damage to the neurons and leading to neuro changes and eventually herniation and brain death.
Etiology
Anything that causes increased volume of brain tissue, blood, or cerebrospinal fluid within the skull – cerebral edema, hemorrhage, hydrocephalus, hypertension, cerebral vasodilation. Could also be caused by a space-occupying lesion such as a tumor or mass.
Desired Outcome
Minimize intracranial pressure to prevent any damage to nerve tissue and prevent long-term neurological deficits.
Increased Intracranial Pressure (ICP) Nursing Care Plan
Subjective Data:
- Confusion
- Memory Loss
Objective Data:
- Altered LOC
- Pupil changes
- Babinski Reflex
- Posturing
- Seizures
- Cushing’s Triad (impending herniation)
- Abnormal Resps
- Wide pulse pressure
- Bradycardia
- Elevated Temp
Nursing Interventions and Rationales
- Frequent neuro checks (q1h)
Neurological changes related to increasing ICP may be subtle or may occur rapidly. Frequent detailed neuro checks allow changes to be recognized quickly so that interventions can be initiated.
- Monitor Temperature and hemodynamics, including MAP and CPP
With a loss of autonomic regulation, a patient’s temperature could become very elevated (104°+).
Monitor hemodynamics to assess for Cushing’s Triad and to evaluate Cerebral Perfusion Pressure (MAP – ICP).
- Avoid sedatives or CNS depressants if possible
These medications could alter our neuro checks, so we avoid them whenever possible in order to get an accurate neuro exam.
- Administer ordered medications:
- Osmotic Diuretics
- Hypertonic Saline
- Corticosteroids
- Osmotic Diuretics (Mannitol) – decrease edema
- Hypertonic Saline (3% saline) – decrease edema
- Corticosteroids – decrease inflammation
These medications help to decrease the circulating CSF volume as well as to decrease any cerebral edema. This decreases the pressure within the cranial cavity based on the Monro-Kellie Hypothesis.
- Prepare patient for surgical intervention
- Craniectomy
- External Ventricular Drain
A craniectomy is used to remove a portion of the skull (bone flap) in order to allow space for cerebral swelling.
External Ventricular Drain (EVD) is a catheter placed into the ventricle to drain blood or CSF in the event of an elevated ICP.
- Level and Zero EVD to tragus (external auditory meatus). Maintain open per orders (i.e. open at 10 cm H2O)
EVD should be leveled to the tragus to be approximately in line with the 4th ventricle in the brain. 10 cmH2O correlates to approximately 7-8 mmHg ICP – therefore any increase in the ICP above 7-8 would cause CSF to drain. If the EVD is not leveled appropriately, too much or too little CSF could drain. Too little drainage could cause increased ICP and possible brain herniation.
- Monitor Electrolytes and Urine Output
If the patient is on mannitol or hypertonic saline, this could cause fluctuations in sodium levels, which could lead to seizures.
Urine output should be monitored to ensure diuresis with mannitol, but also to monitor for the possible development of diabetes insipidus.
- Perform interventions to minimize ICP:
- Maintain HOB 30-45°
- Decrease stimuli
- Avoid valsalva maneuvers
- Maintain HOB 30-45°
- HOB < 30 = increased blood flow to brain → Increased ICP
- HOB > 45 = increased intrathoracic pressure → decreased venous outflow from brain → increased ICP
- Decrease stimuli
- Agitation or stress can cause increased ICP
- Avoid valsalva maneuvers
- Coughing or bearing down can cause increased ICP
References
Transcript
