nursing management of the client with increased intracranial pressure

NURSING MANAGEMENT

OF THE CLIENT WITH

INCREASED INTRACRANIAL

PRESSURE (ICP)

MR.ANILKUMAR B R M.SC NURSING

LECTURER MEDICAL SURGICAL NURSING

• The rigid cranial vault contains brain tissue (1,400

g), blood (75 mL), and CSF (75 mL)

• The volume and pressure of these three

components are usually in a state of equilibrium

and produce the ICP.

• ICP is usually measured in the lateral ventricles;

normal ICP is 10 to 20 mm Hg.

THE RIGID CRANIAL VAULT

THE RIGID CRANIAL VAULT

THE MONRO-KELLIE HYPOTHESIS

•The Monro-Kellie hypothesis states that

because of the limited space for expansion

within the skull, an increase in any one of

the components causes a change in the

volume of the others.

THE MONRO-KELLIE HYPOTHESIS

ETIOLOGY

• Increased ICP is a syndrome that affects many patients

with acute neurologic conditions.

• This is because pathologic conditions alter the relationship

between intracranial volume and pressure. Although an

elevated ICP is most commonly associated with head

injury, it also may be seen as a secondary effect in other

conditions, such as brain tumours, subarachnoid

haemorrhage, and toxic and viral encephalopathies.

CLINICAL MANIFESTATIONS

•When ICP increases to the point at which the

brain’s ability to adjust has reached its limits,

neural function is impaired; this may be manifested

by clinical changes first in LOC and later by

abnormal respiratory and vasomotor responses.

CLINICAL MANIFESTATIONS

•Any sudden change in the patient’s condition, such as

restlessness (without apparent cause), confusion, or

increasing drowsiness, has neurologic significance.

• As ICP increases, the patient becomes stuporous,

reacting only to loud auditory or painful stimuli. At

this stage, serious impairment of brain circulation is

probably taking place, and immediate intervention is

required.

CLINICAL MANIFESTATIONS

•As neurologic function deteriorates further, the

patient becomes comatose and exhibits abnormal

motor responses in the form of decortication,

decerebration, or flaccidity.

•When the coma is profound, with the pupils

dilated and fixed and respirations impaired, death

is usually inevitable.

DECORTICATION, DECEREBRATION POSTURE

OTHERS CLINICAL MANIFESTATIONS

1. Changes in LOC

2. Changes in vital signs

3. Pupillary changes (due to increased pressure on the optic

and oculomotor nerves

4. Headache is increasing in intensity and aggravated by

movements and straining.

5. Vomiting recurrent with little or nausea, esp. in early

morning.

CLINICAL MANIFESTATIONS

6. Papilledema from optic nerve compression.

7. Restlessness, headache, forced breathing pattern,

purposeless movements and mental cloudiness.

8. Seizures activity: focal or generalized

9. Decreased brain stem function (CN deficits such as loss

of control reflexes and ability to swallow.

10. Pathologic reflexes: Babinski, grasp, chewing, sucking.

ASSESSMENT AND DIAGNOSTIC FINDINGS

1. The diagnostic studies used to determine the underlying

cause of increased ICP .

2. Cerebral angiography

3. Computed tomography (CT) scanning

4. Magnetic resonance imaging (MRI) or positron emission

tomography (PET).

5. Transcranial Doppler studies provide information about

cerebral blood flow.

•Lumbar puncture is avoided in patients with

increased ICP because the sudden release of

pressure can cause the brain to herniate.

COMPLICATIONS

1. Complications of increased ICP include brain stem

herniation

2. Diabetes insipidus syndrome

3. Inappropriate antidiuretic hormone (SIADH)

4. Brain stem herniation results from an excessive increase

in ICP, when the pressure builds in the cranial vault and

the brain tissue presses down on the brain stem.

MANAGEMENT

• Increased ICP is a true emergency and must be treated

promptly.

• Invasive monitoring of ICP is an important component of

management, but immediate management to relieve

increased ICP involves decreasing cerebral edema,

lowering the volume of CSF, or decreasing cerebral blood

volume while maintaining cerebral perfusion.

• These goals are accomplished by:

1. Administering osmotic diuretics and corticosteroids

2. Restricting fluids, draining CSF.

3. Controlling fever maintaining systemic blood pressure

and oxygenation, and reducing cellular metabolic

demands.

MONITORING ICP

•The purposes of ICP monitoring are to identify

increased pressure early in its course (before

cerebral damage occurs), to quantify the degree

of elevation, to initiate appropriate treatment, to

provide access to CSF for sampling and drainage,

and to evaluate the effectiveness of treatment.

MONITORING ICP

•An intraventricular catheter

(ventriculostomy), a subarachnoid bolt, an

epidural or subdural catheter, or a fiberoptic

transducer-tipped catheter placed in the

subdural space or the ventricle can be used to

monitor ICP.

ICP MONITORING

ICP MONITORING

ICP MONITORING

DECREASING CEREBRAL EDEMA

• Osmotic diuretics (mannitol) may be given to dehydrate

the brain tissue and reduce cerebral edema.

• They act by drawing water across intact membranes,

thereby reducing the volume of brain and extracellular

fluid.

• An indwelling urinary catheter is usually inserted to

monitor urinary output and to manage the resulting

diuresis.

OSMOTIC DIURETICS (MANNITOL

1. Corticosteroids (e.g., dexamethasone) help

reduce the edema surrounding brain tumours

when a brain tumour is the cause of increased

ICP.

2. Another method for decreasing cerebral

edema is fluid restriction .

MAINTAINING CEREBRAL PERFUSION

• The cardiac output may be manipulated to provide

adequate perfusion to the brain.

• Improvements in cardiac output are made using fluid

volume and inotropic agents such as dobutamine

hydrochloride.

• The effectiveness of the cardiac output is reflected in the

cerebral perfusion pressure, which is maintained at

greater than 70 mm Hg.

DOBUTAMINE HYDROCHLORIDE.

REDUCING CSF AND INTRACRANIAL BLOOD VOLUME

• CSF drainage is frequently performed because the

removal of CSF with a ventriculostomy drain may

dramatically reduce ICP and restore cerebral

perfusion pressure. Caution should be used in

draining CSF because excessive drainage may

result in collapse of the ventricles.

CONTROLLING FEVER

• Preventing a temperature elevation is critical

because fever increases cerebral metabolism

and the rate at which cerebral edema forms.

• Strategies to reduce temperature include

administration of antipyretic medications, as

prescribed, and use of a cooling blanket.

MAINTAINING OXYGENATION

• Arterial blood gases must be monitored to

ensure that systemic oxygenation remains

optimal.

• Hemoglobin saturation can also be optimized

to provide oxygen more efficiently at the

cellular level.

NURSING PROCESS: THE PATIENT WITH INCREASED ICP

• The neurologic examination should be as complete as the patient’s

condition allows. It includes an evaluation of mental status, LOC,

cranial nerve function, cerebellar function (balance and

coordination), reflexes, and motor and sensory function.

• Ongoing assessment will be more focused, including pupil checks,

assessment of selected cranial nerves, frequent measurements of

vital signs and intracranial pressure, and use of the Glasgow Coma

Scale.

NURSING DIAGNOSIS

• Ineffective airway clearance related to diminished protective reflexes

(cough, gag)

• Ineffective breathing patterns related to neurologic dysfunction (brain

stem compression, structural displacement)

• Ineffective cerebral tissue perfusion related to the effects of increased

ICP

• Deficient fluid volume related to fluid restriction

• Risk for infection related to ICP monitoring system (fiberoptic or

intraventricular catheter)