Nr202 Test 5 Intracranial Pressure Icp

Front 1

Define Intracranial Pressure and list the intracranial components

Back 1

• Definition: Pressure exerted by the combined volume of three intracranial components:
- brain tissue
- cerebrospinal fluid
- blood

Front 2

What is the Monroe-Kelly hypothesis

Back 2

Monroe-Kelly hypothesis: ICP remains stable as long as the volume that is added is balanced by the volume that is displaced.
- ICP = CSF volume + blood volume + volume of brain tissue

Front 3

Intracranial Pressure (ICP) – what is normal =

Back 3

• 0-15 mm Hg
• 60- 180 cm H20
- Cerebral Volume
• Brain tissue = 80%
• Cerebral blood volume = 10%
• cerebral spinal fluid [CSF fluid= 10%

Front 4

• What is cerebral blood flow provided by? ______ What is the definition of this term

Back 4

• Cerebral blood flow provided by: Cerebral Auto-regulation:
- Maintenance of Cerebral Blood Flow by altering the diameter of the arterioles
- In response to changes in Cerebral Perfusion Pressure

Front 5

• What is Cerebral Perfusion Pressure (CPP):

Back 5

- measurement provides: estimate of adequacy in 02 circulation
- difference between the mean systemic arterial pressure and the mean intracranial
pressure. Usually between 60-100 mm Hg

Front 6

Auto-regulation is ineffective with:

Back 6

ischemia
•hypoxia hypercapnia
brain trauma

Must have systolic BP between 60-140.
Must have ICP < 30

Front 7

Hypercapnia-What is an increased and decreased CO2 level mean and what does a decreased PO2 level mean, what are these levels?

Back 7

- pC02 >45 = cerebral vasodilation
- pC02 <35 = cerebral vasoconstriction
• p02 < 60 = cerebral vasodilation
Cycle for brain swelling

Front 8

Increased Intracranial Pressure • What is the Etiology

Back 8

- Increased brain volume
-Cerebral edema intracranial mass
- Increased cerebral blood flow-Oxygenation in the brain
• intracranial bleed, cerebral aneurysm, elevated pC02, hypoxia - Increased cerebrospinal fluid
• hydrocephalus, meningitis, tumors that obstruct CSF flow
Brain tumor/hemorrhage

Front 9

Conditions Increasing ICP

Back 9

• Sneezing
• Vomiting
• Coughing
• Suctioning (frequent)
• Valsava
• Increased activity
• Increased PaC02
• Hyperthermia
• Seizures
• Neck flexion
• Emotional upset
• Decreased PaO2

Front 10

Complications of ICP

Back 10

• Brain herniation
• Diabetes insipidus (deficiency of ADH secretion causing increased u/o and dehydration)
• Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) - increased ADH secretion causing decreased u/o and fluid overload.
• Seizures

Front 11

Symptoms of increased ICP
• Stage I

Back 11

• Stage I
- altered vision (blurred, double)
- confusion (first to time, forgetful)
- drowsiness (lethargy, more stimulation needed, restless, irritable)
- breathing changes (depends on LOC-cheyne stokes)
- slight ipsilateraly pupillary changes (sluggish/ovoid)
- ptosis-drooping of eyelids
- early am HA/projectile vomiting
- motor--pronator drift, subtle weakness to hemiplegia on contralateral side
• Middle to late stages (cushings)

Front 12

Symptoms of increased ICP Stage 2
Stage 3

Back 12

• Stage 2
- Systemic arterial vasoconstriction
• attempt to overcome ICP

• Stage 3
- decreased arousal
- Cheyne Stokes to apneustic
- Hyperventilation
- widened pulse pressure
- bradycardia

• Cushings signs: widened pulse pressure, decreased pulse, decreased respirations. - Stage 2-3
- body's last attempt to compensate

Front 13

Symptoms of increased ICP
• Stage 4 (decompensation)

Back 13

Symptoms of increased ICP
• Stage 4 (decompensation)
- Herniation
• unarousable
• tachycardic, hypotension, narrowed pulse pressure
• tissue hypoxia and brain death
• posturing from decorticate to decerebrate
• pupils from small & reactive or sluggish to fixed and dilated
• Absence of dolls eyes [negative] negative respirations

Front 14

Compensatory Mechanisms for Increased ICP

Back 14

- shunting of CSF into spinal subarachnoid space
- increased CSF absorption
- Decreased CSF production
- shunting of venous blood out of skull

Front 15

Decompensation

Back 15

- Decompensation: herniation (displacement of brain tissue to another area of the
brain or outside cranial vault)
- blood supply to medulla is cut off
- pupils fixed and dilated
- from decorticate to decerebrate posture
• irreversible brain damage
Herniation

Front 16

Diagnostics of ICP:

Back 16

• CT or MRI to determine possible causes of ICP
- CT: detailed outlines of bone, tissue & fluid structures; reflect shift of structures and acute hemorrhage
- MRI: graphic image of bone, fluid & soft-tissue structures with more defined image of anatomical details;
Normal CT Scan
• Intracerebral Edema & Hemorrhages MRI
• CBF monitoring (blood flow)
- Transcranial Doppler ultrasonography o aimed through cranial "windows"
- Radioisotope brain scan
• Damaged areas absorb more of the isotope
EEG Tracings
• A: normal
• B: Generalized slowing
• C: Temporal spikes (seizures)
• D: Electrocerebral silence

Front 17

Interventions for ICP

Back 17

• Hypothermia: decreases 02 consumption, but may decrease CBF unless induced barbiturate coma
• Craniotomy (bone flap) remove some bone of skull-more room for the brain
• Hemodynamic monitoring:
- MAP between 115-120, less than 140 fluid up
- PAWP 14-16
ICP monitoring

Normal 0-15
- Keep less than 30
• Ventriculostomy, shunt: drainage of CSF
- against positive pressure to prevent collapse
- sterile technique

Front 18

ICP Measurement Techniques

Back 18

• Intraventricular
- Ventriculostomy catheter placed through burr hole into lateral ventricle
- Connected to pressure tubing & transducer
• Intraparenchymal catheter
- Fiberoptic transducer tipped catheter placed directly into brain tissue
- Used in patients with displaced or compressed ventricles
• Subaraclmoid Technique
- Subaraclmoid screw extended into the subdural or subaraclmoid space
• Epidural Sensor
- Placement of epidural device between skull & dura

Front 19

Medications
- Corticosteroids

Back 19

- Corticosteroids (dexamethasone or Decadron) reduces ICP through unknown mechanism. Side effects: GI ulcers and bleeding, and elevated blood glucose .
• Research: Ineffective with severe head-injury, but reduces vasogenic edema associated with brain tumors, abscesses, & spinal cord tumors

Front 20

Medications-Calcium Channel Blockers

Back 20

Calcium Channel Blockers (nimodipine, nicardipine) prevent cerebral vasospasm, however cerebral vasodilation increases ICP-contraindicated with space-occupying lesions or cerebral edema.

Front 21

Medications-Sodium Nitroprusside

Back 21

Sodium Nitroprusside: used with severe intracranial hypertension; should maintain MAP of at least 130.

Front 22

Medications-Barbituates:

Back 22

: phenoobarbital: may be used to induce coma (decreases metabolic & 02 demands)
• also:
- suppresses seizure activity,
- reduces restlessness & irritability
• research: increased survival

Front 23

Medications-Beta Blockers

Back 23

Beta Blockers: Labetalol (Trandate) decreases ICH, improves CPP, without increased ICP. Contraindicated in patients with space occupying lesions or cerebral edema

Front 24

Medications: Sedatives:

Back 24

Sedatives: phenobarbital, propofol, versed, ativan."Lorazepam”
• Baseline evaluation of mental & neurological status
• Periodic discontinuation
- Analgesics: Fentanyl or MS frequently used;
• patients in pain become combative, restless & agitated
- Antipyretics: Acetaminophen is used to control fever.

Front 25

Medications:
stool softeners: - Anticonvulsants: (dilantin, tegretol, valium)
- Histamine H2 blockers

Back 25

stool softeners: colace
- Anticonvulsants: (dilantin, tegretol, valium) used to manage seizure activity
- Histamine H2 blockers (pepcid, tagamet, zantac) prevent GI irritation & bleed

Front 26

Neuromuscular Blockades (Vecuronium)

Back 26

- Neuromuscular Blockades (Vecuronium)
• used to counteract increases in ICP associated with reflex motor responses to suctioning and mechanical ventilation
• trane of four
- four stimuli delivered at intervals of 0.5 sec.
- Ulner at wrist
- thumb should twitch 2-3 times
• must sedate & treat for pain • must be on ventilator

Front 27

The doctor has just ordered IV albumin and IV lasix for the patient with cerebral edema. Which medication should be given first?

Back 27

Albumin

Front 28

Nursing Interventions

Back 28

• Goals: reduce ICP, improve CPP, reduce brain shift
-IV fluids (Avoid hypoosmolar solutions D5W-goes more into cells)
- Neuro assessment every 1-2 h
- If on ventilator, minimal suctioning,
- hyperventilate as ordered (keep pC02 above 30)
- Elevate HOB 30-45 degrees, head midline
- Avoid knee flexion
- Assess bowel and bladder function
- Do not cluster activities
- Quiet, calm environment
- Avoid Valsalva maneuver (coughing, sneezing)
- If administering tube feedings, give at room temperature
- If ICP monitor, monitor for infection, change dressing 24-48 hours, monitor for
leaking CSF (clear fluid which tests glucose +) -no nose blowing
- Monitor I & 0, possible fluid restriction

Front 29

Care of the Client with a Craniotomy

Back 29

• Craniotomy: surgical procedure performed to gain access to the intracranial contents and accommodate brain swelling
• Indications
- Intracranial neoplasms
- Head injuries (hematoma, cerebral edema or depressed skull fracture)
Space occupying lesions (bleeds, abscess, aneurysms, arteriovenous
malformations)

Front 30

Preoperative nursing care

Back 30

• Permit signed
• Hair cut and shaved
• surgical scrub/ shampoo
• report breaks in skin of scalp
• record baseline neuroassessment
• foley or NG if ordered (may be done after anesthesia)
• explain post-op environment (monitoring equipment, ventilator, communication)

Front 31

Post-op Nursing Care

Back 31

- Prevent injury & infection
• Care same as pt with increased ICP
• Assess wound, eyes, ears, nose for CSF leaks and/or infection
• Provide protective eye care
• NPO until fully conscious (and extubated)
• Do not lower head in Trendelenburg or place in supine position
• Avoid placing on operative side if large tumor or bone removed
• Maintain mobility of joints and extremities - assess motor/sensory responses
- PROM q 12 h
• Improve body image
Encourage use of wigs, turbans, and scarves when dressings removed
- encourage use of normal cosmetics
- promote self-care

Front 32

Post-op Nursing Care
speech

Back 32

• Improve speech
- provide audiovisual aids as needed
- speak in simple, slow instructions
- refer to speech therapist

Front 33

Cerebral Aneurysm
• History

Back 33

• History
- adults 35-60 y.o., female
- atherosclerosis
- congenital defect
- head trauma
- hypertension
- familial
- cigarette smoking, use of cocaine
- use of OTC med (nasal sprays or antihistamines)

Front 34

Cerebral Aneurysm Pathophysiology

Back 34

• Most located at bifurcations in or near Circle of Willis
• Act as space occupying lesions
• Saccular and Berry
• Rupture due to thin walls
- Most common first indication is acute subarachnoid hemorrhage (Bleed), or intracerebral
hemorrhage

Front 35

Cerebral Aneurysm
- Manifestations

Back 35

• many have no manifestations and no problems
• headaches
• occasional ptosis and dilated pupil and diplopia or blurred vision
• pain above and behind the eye
• nausea and vomiting
• stiff neck
• dysrythmias and vasospasm
• hemiplegia/hemiparesis
• other signs of ICP
• Warning signs (50% of patients) - headaches
-lethargy
- neck pain
- "noise in the head"
- optic, or oculomotor dysfunction

Front 36

Cerebral Aneurysm
Diagnostic tests
Surgery

Back 36

• Diagnostic tests
• CT Scan
- Cerebral arteriography
Surgery is treatment of choice Clipping or coiling

Front 37

Presurgical Nursing Interventions

Back 37

- Interventions to treat or prevent ICP
- Sedation
- Quiet environment
- Prevention of coughing, & constipation
- hot or cold beverages may be prohibited
- limit visitors

Front 38

Post-surgical nursing interventions

Back 38

• Baseline neuro assessment
• Monitor changes in neuro status
• possible mechanical hyperventilation
• I and O
• vital signs (esp. BP)
• monitor for dysrythmias
• talk directly to the patient
• monitor sodium
• monitor for vasospasm
- causes decreased CBF, depriving brain tissue of oxygen
- treat with triple H therapy & nimodipine
• hypervolemia
• induced hypertension
• hemodilution
• close monitoring of hemodynamic parameters
• monitor for pulmonary edema

Front 39

Craniocerebral Trauma
• Types of Injuries

Back 39

-Acceleration Injury: head struck by a moving object
- Deceleration Injury: head hits a stationary object
- Acceleration-Deceleration Injury (coup-contrecoup phenomenon): head hits object
and the brain "rebounds"
- Deformation Injury Skull Fractures

Front 40

Craniocerebral Trauma
• Linear
• Depressed:

Back 40

Linear: simple clean break
- Most common
- force over wide area of skull
• Depressed: - bone fragments may penetrate into the brain tissue

Front 41

Craniocerebral Trauma
• Basilar:

Back 41

• Basilar: floor of skull
- serious
- contact between CSF and sinuses
- CSF may leak through sinus
- allow bacteria to contaminate CSF
- Raccoon Eyes
_ Battle Sign Behind ear on mastoid bone

Front 42

Craniocerebral Trauma

• Concussion

Back 42

- Description: Transient, temporary neuro dysfunction (least serious)
Usually loss of consciousness from seconds to hours
• retrograde amnesia, HA, drowsiness, visual disturbances
• postconcussive syndrome: HA, inability to concentrate, memory problems, dizziness, irritability
- Mechanism of Injury: Acceleration-Deceleration
- Prognosis: Most benign form of brain injury

Front 43

Craniocerebral Trauma
• Contusion
• Hemorrhage diffused
cerebral edema & hemorrhage peak in ___-____ hrs
larger areas may expand over ___-____ days

Back 43

• Contusion
- Description: Bruise on the surface of the brain
• Hemorrhage diffused
- Mechanism of Injury: Brain strikes inner skull (coup & contrecoup)
- Prognosis: Varies depending on location & degree
• cerebral edema & hemorrhage peak in 12-24 h
• larger areas may expand over 2-3 days

Front 44

Craniocerebral Trauma- Manifestations:

Back 44

• loss of consciousness
• behavior changes
• ICP
• hemiparesis
• abnormal posturing
• bradycardia
• seizure
• respiratory arrest
• Hypotension

Front 45

Intracranial Hematoma
Subdural Hematoma venous bleed
location and etiology

Back 45

• Subdural Hematoma venous bleed
- Location: bleeding or clot between dura and brain
- Etiology: trauma, coagulopathies, aneurysm rupture. More frequently a venous
bleed

Front 46

Intracranial Hematoma
Subdural Hematoma venous bleed
Prognosis:

Back 46

- Prognosis:
• Acute: sx in 24-48 h. needs immediate intervention
• Subacute: sx in 48hr- 2 wk
• Chronic: minor head injury in elderly. Sx in weeks to months
• -May mimic dementia

Front 47

Intracranial Hematoma
Subdural Hematoma venous bleed
- Manifestations
- treatment

Back 47

- Manifestations
• Acute: change in LOC, pupillary signs, hemiparesis, increasing BP, decreasing HR, slowing RR
- treatment: burr holes, and insertion of drainage catheters

Front 48

• Epidural Hematoma Arterial Bleed

Location
Etiology
Prognosis

Back 48

• • Epidural Hematoma Arterial Bleed
- Location: bleeding or clot between skull and dura
- Etiology: head injury, often from arterial bleed
• linear fx across temporal bone lacerating middle meningeal artery
- Prognosis: considered an extreme emergency; marked neurologic deficit or resp arrest may occur within minutes.
- Death from herniation not bleeding

Front 49

• • Epidural Hematoma Arterial Bleed
- Manifestations:

Back 49

- Manifestations:
• "talk & die syndrome" period of lucidity, then rapid deterioration & death
• deterioration of consciousness,
• ipsilateral dilation and fixation of a pupil
• Contralateral paralysis of an extremity

Front 50

• Intracerebral Hematoma
-Description
- Etiology
- Prognosis
- Manifestations

Back 50

Description: a collection of 25 mL or more of blood within the brain tissue
- Etiology: MV A most common cause
- Prognosis: surgical intervention only if continued expansion
- Manifestations: insideous onset, HA, development of focal neuro deficits

Front 51

• Intracerebral Hematoma
- Complications

Back 51

- Complications
• increased ICP
• Pulmonary edema: neurogenic cause
• Seizures: keep sx equipment close, padded rails, IV diazepam (# 1 protect patient)
CFS leak clear, watery drainage.
Test with blood glucose strips
- Do not clean, irrigate or suction areas of drainage
- Instruct patient not to blow nose, sniff or put finger in nose or ear.