Nursing Care Plan (NCP) for Increased Intracranial Pressure (ICP)

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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

 

Writing a Nursing Care Plan (NCP) for Increased Intracranial Pressure (ICP)

A Nursing Care Plan (NCP) for Increased Intracranial Pressure (ICP) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

In this lesson today, we’re going to take a look at the care plan for increased intracranial pressure, also known as ICP. In this lesson, we will briefly take a look at the pathophysiology and etiology of increased ICP. We’re also going to take a look at additional things that would be included in an ICP care plan, like subjective and objective data that your patient may present with as well as the necessary nursing interventions and rationales. 

 

Increased ICP is defined by an increase in pressure in the skull caused by an increase in the volume of brain tissue, blood, cerebrospinal fluid, or by the presence of a space occupying lesion. The increased pressure compresses brain tissue, which causes damage to the neurons leading to neuron changes, eventual herniation and brain death. Causes include cerebral edema, hemorrhage, hydrocephalus, hypertension, cerebral visa, dilation, a tumor, or a mass.

 

The desired outcome is to minimize ICP, to prevent any damage to nerve tissue and prevent long-term neurological deficits. Okay, so let’s take a look at some of the subjective and objective data that your patient with increased ICP may present with. Remember, subjective data are going to be things that are based on your patient’s opinions or feelings. These things might include confusion or memory loss. 

 

Objective data includes altered level of consciousness, pupil changes, but Babinski reflex, posturing, seizures, Cushing’s triad, which indicates impending herniation and includes abnormal respirations, a wide pulse pressure and bradycardia. We will also see an elevated temperature in these patients.  

 

Okay, so let’s jump into some of the nursing interventions for increased ICP. Complete neuro checks every hour as neurological changes related to increased ICP may be subtle or rapid, so  Frequent detailed neuro checks allow changes to be recognized quickly. Interventions can be initiated in elevated temperatures, sometimes as high as 104 is common with increased ICP because of the loss of autonomic regulation. Be sure to monitor your patient’s temperature, also monitoring hemodynamics to assess for Cushing’s triad and to evaluate cerebral perfusion pressure, which is the difference between mean arterial pressure and intracranial pressure. 

 

For patients with increased ICP, sedatives and CNS depressions need to be avoided because they can alter neurotrax checks. Common order medications include osmotic diuretics like mannitol, and hypertonic saline to decrease edema and corticosteroids to decrease inflammation. In some cases, it might be necessary to prepare the patient for a surgical intervention, like a craniectomy. This will remove a portion of the skull to allow space for swelling or placement of an external ventricular drain in the event of an elevated ICP. 

 

The EVD or external ventricular drain should be leveled to the tray, to be approximately in line with the fourth ventricle of the brain. Any increase in ICP above seven to eight would cause cerebrospinal fluid to drain because 10 centimeters of water correlates to approximately seven to eight millimeters of mercury ICP. If that EVD is not leveled properly, too much or too little cerebrospinal fluid could drain and too little drainage could cause increased ICP and possible brain herniation. Because of medications given to manage ICP like mannitol, it is important to monitor electrolytes and urine output. Mannitol and hypertonic saline can increase sodium levels, which could cause fluctuation in sodium levels, which could lead to seizures. Urine output should be monitored to verify diuresis. There are certain interventions that are utilized to minimize ICP, like maintaining the head of the bed between 30 and 45 degrees. Below 30 and above 45 can both increase ICP. You also want to decrease stimuli as agitation can increase ICP in your patient, and avoid Valsalva maneuvers because coughing and bearing down can increase ICP also. 

 

Here is a look at the completed care plan for increased ICP. Let’s do a quick review. Increased ICP occurs when there is an increase in pressure in the brain cavity or skull, which compresses the brain tissue and leads to neuron changes and damage. Subjective data includes confusion and memory loss. Objective data includes altered LOC, pupil changes, Babinski reflex, seizures, Cushing’s triad, posturing, and elevated temperature. Provide frequent neuro checks every hour to decrease complications. Monitor your patient’s temperature, their hemodynamics, electrolytes and their urine output. Avoid sedatives and CNS depressants to prevent alterations in your neuro checks. Administer osmotic diuretics and corticosteroids. Level and zero your EVD.   Perform interventions like keeping the head of the bed at between 30 and 45 degrees, and decreasing stimuli to prevent increases in ICP. Finally prepare the patient for a craniectomy or EVD placement if necessary.

 

We love you guys. That is it for this lesson on the care plan for increased ICP. Go out and be your best self today and as always, happy nursing!

 

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