Increased Intracrnial Pressure

1. INCREASED INTRACRNIAL PRESSUREWhen hydrocephalus is identified, a ventriculostomy
"Brain swelling with edema and blood collects withinshould be inserted, Slow removal can also be
the brain."accomplished by passive gravitational drainage
2. ANATOMY AND PHYSIOLOGY OF BRAIN:through the ventriculosomy.b. DECOMPRESSIVE
* Brain the most critical organ of human body.CRANICTOMY;
* Protected through three protective structures;Decompresive cranictomy removes the rigid confines
A. Skull-bony structureof the bony skull, increasing the potential volume of
B. Meningies-Dura, Arachnoid, Piamatterthe intracranial content, cranictomy alone lowered ICP
C. Cerebrospinal Fluid.15 PERCENT, but opening of the bony skull resulted in
3. PHYSIOLOGY OF INTRACRANIAL PRESSURE:an average decrease in ICP of 70 percent.
Intracranial pressure is normal at 4-15mmhg and13. NURSING DIAGNOSIS AND INTERVENTIONS:a.
50-300mmof water. Skull is not flexible structure. IfNURSING DIAGNOSIS
pressure of any of the above three will increaseIneffective breathing pattern and ventilation related
compensatory decrease in other two. If exceed theto hypoxia.a. NURSING INTERVENTION:
compensatory efforts increased intracranial pressure.• Reassure person that measures are being
A. CEREBRAL BLOOD FLOW;taken to ensure safety.
Brain injury can result from brain stem compression• Distract person from thinking about
and reduction in cerebral blood flow.anxious state by having him or her maintain eye
Ohm's lawcontact with you; say, "Now look at me breathe
CBF = (CAP-JVP) \ CVRslowly with me like this".
CAP=CAROTID ARTERIAL PRESSURE• Explain that one can learn to overcome
JVP= JUGLARVENOUS PRESSUREhyperventilation through conscious control of
CVR= CEREBROVASCULAR RESISTANCEbreathing.
B. CEREBRAL PERFUSION PRESSURE;• Discuss possible causes, physical and
A clinical surrogate for the adequacy of cerebralemotional and methods of coping effectively.b.
perfusion. CPP is defined as mean arterial pressureNURSING DIAGONSIS:
(MAP) minus ICPAltered Nutrition less than body requirement related
CPP= MAP-ICP.to metabolic changes and inadequate intake.
4. PATHOPHSIOLOGY:NURSING INTERVENTION:
Oedematous brain tissues lead to• Determine daily caloric requirements that
inflammation\hematoma formationo increase pressureare realistic and adequate. Consult with dietitian.
in the cranial cavityo compensatory decrease in• Weight daily, Monitor laboratory results.
cerebral blood flowo cerebral blood flowo cerebral• Explain the importance of adequate
hypoxiao ischemia of vasomotor centreo CUSHING'Snutrition. Negotiate with client intake goals for each
sign (increase B.P, decrease pulse) - late sign ofmeal.
increased intracranial pressure suggest irreversible• Plan care so that unpleasant or painful
brain damage.procedures do not take place before meals.
5. CAUSES:a. Mass lesion abscessesb. Extadural• Provide pleasant, relaxed atmosphere for
hematomac. Subdural Hematomad. Subacutesubduraleat in (no bedpans insight).
intracerebral hemorrhagee. Strokef. Hepatic• Arrange plan of care to decrease or
encephalopathy.g. Brain Herniationh. Seizures.eliminate nauseatic odors.
6. CLINICAL MANIFASTATION;• Maintain good oral hygiene.
• a. Severe Headache (e.g. head trauma,• Try commercial supplement available in
subarachnoid Hemorrhage)many forms (liquid, powder, pudding).
• b. Confusion or Diminished responsiveness• Establish intake goals with client, physician
• c. Hemiparesisand nutritionist.c. NURSING DIAGNOSIS:
• d. SeizersAltered temperature related to damage to
• e. Spontaneous periorbital bruisingtemperature regulating mechanism.
• f. BradycardiaNURSING INTERVENTION:
• g. Respiratory Depression• Teach the person the importance of
• h. Contra lateral papillary dilationadequate intake (> or = 20,000ml per day unless
• i. Loss of gag reflexcontraindicated by heart or kidney disease)
• j. Glass cow coma scalelessthen or equals• Monitor intake and output.
to 8• Assess whether the clothing or bed
• k. Temperature may risecovers are too warm for the environment.
• l. Cushing triad: increased systolic blood• Teach the importance of increasing fluid
pressure, widened pulse pressure and slow heartintake during warm weather and exercise.
rate.• Explain the need to wear loose fitting
• m. Decorticate or decelerating posturing.clothing.
• n. Occasional transient elevation associate• Teach the early sign of hyperthermia or
with Sneezing, Cough,heat stroke.
DIAGNOSTIC FINDINGS• Flushed skin.
7. ROLE OF COMPUTED TOMGRAPHY:• Headache
CT scan may suggest elevated ICP based on the• Fatigue
presence of mass lesion, midline shift. Since ICP• Loss of appetite.d. NURSING DIAGNOSIS:
monitoring is also associated with a small risk ofPotential for impaired skin integrity related to bed
serious complication that is CNS infection, intra cranialrest and hemi paresis.
hemorrhage.NURSING INTERVENTION:
8. TYPES OF MONITORS• Assess the integrity of skin.
A. INTRVENTRICULAR;• Identify the stage of pressure ulcer
Intraventricular monitors are considered the 'golddevelopment
standard' of icp monitoring catheters. They are• Assess the status of ulcer: size, depth,
surgically placed into the ventricular system and aedges, undermining.
fixed into the drainage bag and pressure transducer• Assess necrotic tissues, type, (color,
with a three way stopcock .It allow the treatment ofconsistency, adherence) and amount.
some elevated ICP via drainage of csf.• Wash reddened area gently with a mild
B. INTRAPARENCHYMAL;soap rinse thoroughly to remove soap and pat dry.
Consist of a thin cable with an electronic or fiber• Gently massage healthy skin around the
optic transducer at the tip. The most widely usedaffected area to stimulate circulation.
device is the fiber optic Camino system. These• Increase protein and carbohydrate intake
monitors can be inserted directly into the brainto maintain a positive nitrogen balance.
parenchyma via a small hole drilled in the skull. It• Weight the person daily.
cause ease of placement and lower the risk of• Determine serum albumin level weekly to
infection.monitor status.e. NURSING DIAGNOSIS:
C. SUBARACHNOID;Altered thought processes (deficit in intellectual
Subarachnoid bolts are fluid coupled systems within afunction, communications) related to brain injury.
hollow screw that can be placed through the skullNURSING INTERVENTION:
adjacent to the dura. The dura is then punctured,• Explain attitude about confusion (in self,
which allows the CSF to communicate with the fluidcaregivers, significant others) Provide education to
column and transducer. The most commonly usedfamily, significant others and caregiver regarding the
subarachnoid monitor is the Richmond bolt. It has lowsituation and method of coping.
risk of infection and hemorrhage.• Maintain standard of empathic, respectful
D. TRANSCRANIAL DOPPLER:care.
Measures the velocity of blood flow with in the• Encourage significant others and care
proximal cerebral circulation. TCD can be used togivers to speak slowly either low pitch and at an
estimate ICP based on characteristic changes inaverage volume.
waveforms that occur in response to increased• Provide respect and promote sharing
resistance to cerebral blood flow. TCD is poor• Pay attention to what person is saying.
predictor of ICP, although in trauma patients. TCD• Pick out meaningful comments and
finding may correlate with outcome at six months.continue talking.
9. GENERAL MANAGEMENT:• Call person by name and introduce your
Evacuation of a blood clotself each time.
Resection of a tumor• Use name the person is prefers, avoid
CSF diversion in the management of hydrocephalus"pops" or "moms"
Treatment of underlying me• Convey to person that you are concerned
Metabolic disorder(through smile and unhurried pace).
10. SYMPTOMATIC TREATEMENT:a. SEDATION AND• Use memory aid if appropriate.
BLOOD PRESSURE CONTROLING:For communication
Keeping the patients appropriately sedated can• Use pad, pencil, alphabets, letters hand
decrease ICP by reducing metabolic demand, venoussignals, eye link head nodes and bell signals.
congestion and the sympathetic responses of• Make flash cards with pictures or words
hypertension and tachycardia.b. POSITIONING:depiciting frequently used phrases (Move my foot,
Patient with elevated ICP should be positioned toglass of water).
maximize venous out floe from the head. Important• Use normal loudness level, speak
maneuver including excessive flexion or rotation ofunhurriedly in short phrases.
the neck avoiding restrictive neck taping, minimizing• Encourage person to take plenty of time
stimuli that could induce valsalva responses, such astalking and to enunciate word carefully with good lip
end tracheal suctioning. Keep head elevated abovemovement.
the heart level at 30 degree to increase venous• Delay conversation when the person is
outflowc. FEVER:tired.f. NURSING DIAGNOSIS:
Elevated metabolic demand in the brain results inImpaired physical mobility related to increased
increase cerebral blood flow and can elevate ICP byintracranial pressure.
increasing the volume of blood in the cranial vaultNURSING INTERVENTION:
.Conversely; decreasing metabolic demand can lower• Perform passive ROM exercise on
ICP by reducing blood flow. Fever increase brainaffected limbs.
metabolism, and has been demonstrated to increase• Support the extremity above and below
the brain injury in animal model. Aggressive treatmentthe joint.
for fever includes acetaminophen and cooling.d.• Use a footdrop.
HYPERVETILATION:• Avoid a prolong period of sitting or lying in
Use of mechanical ventilation to lower paco2 to 26 tothe same position.
30 mmhg has been shown to rapidly reduce ICP• Change the position of the shoulder joints
through vasoconstriction and a decrease in theevery 2 to 4 hours.
volume of intracranial bloode. THERAPEUTIC• Use a small pillow when in fowler's position.
HYPOTHERMIA:• Support the hands and wrist in natural
Hypothermia decrease cerebral metabolism and mayalignment.
reduce ICP and cerebral Blood flow.• If the client is supine or prone, place a
11. PHARMACOLOGICAL TREATEMENT:a.rolled towel or a small pillow under the lumbar
ANTIEPILEPTIC THERAPY:curative or under the end of the rib cag.
Seizures can both complicate and contribute to ICP• If the client is in the lateral position, place
Anti convulsant therapy with EEG doneb. MANNITOL:pillow to support the leg from groin to foot and a
It reduces brain volume by drawing free water outpillow to flex the shoulder and elbow slightly; if
of the tissues and into circulation, where it exertedneeded, support the lower foot in dorsal flexion with
from the Kidney.c. BARBITURATES:a standing.
The use of barbiturate s is predicated on their ability• Use hand and wrist splints.
to reduce brain metabolism and cerebral blood flow,14. TEACHINGS:o Back Careo Hand and foot careo
thus lowering ICP and exerting a neuroprotectiveSuctioningo Medicationso Dieto Deep breathing
effect.exercise
12. SURGICAL TREATEMENT:a. REMOVAL OF15.
CEREBROSPINAL FLUID: