Increase Intracranial Pressure Brain n n Brain tissue
Increase Intracranial Pressure
Brain n n Brain tissue (1, 400 g) Blood (75 m. L) CSF (75 m. L) Normal ICP 10 to 20 mm. Hg
Monro-Kellie Hypothesis n Limited space for expansion in the skull, an increase in anyone of the components causes a change in the volume of the others.
Pathophysiology
n Increase 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.
Elevated ICP most commonly associated with head injury n Secondary Effects q q q Brain tumors Subarachnoid hemorrhage Toxic and viral encephalities
Brain Tumor Decrease Cerebral Blood Flow Ischemia and Cell Death Early Cerebral Ischemia Vasomotor Stimulation (brainstem) Increase Systemic Pressure (s/sx slow pulse, cheyne-stokes resp. , elevated temp. ) Increase ICP
Diagnostic Findings
n n n Cerebral Angiography Computed Tomography (CT) Scanning Magnetic Resonance Imaging (MRI) Positron Emission Tomography (PET) Transcranial Doppler
Cerebral Angiography n n The first image shows normal brain blood flow The second image shows presence of cerebral aneurysm that can cause decease cerebral blood flow may lead to increase ICP
Computed Tomography Scanning n n The first image shows a normal view of the brain The second image shows brain with tumor and edema that may lead to increase ICP
Magnetic Resonance Imaging n n The first image shows normal MRI result The second image shows with brain tumor that causes increase ICP
Positron Emission Tomography n n The first image shows normal PET result The second image shows with brain tumor that may lead to increase ICP
Transcranial Doppler n n The top shows a TCD of a normal artery Bottom shows a severely stenosed internal carotid artery causes decrease cerebral blood flow may lead to increase ICP
ICP Precautions n n n Elevate head of bed 30 degrees. Seizure prophylaxis: Phenytoin will reduce seizures in the first week after injury but does not change the overall outcome. Steroids are ineffective in controlling ICP in the trauma setting.
Manipulation of ICP Blood n n n Decrease cerebral metabolic demand q sedation, analgesia, barbiturates q avoid hyperthermia q avoid seizures Hyperventilation q decreases blood flow to brain q only acutely for impending herniation Mannitol
Manipulation of ICP Brain n Mannitol q q n n dehydrate the brain, not the patient! monitor osmolality Hypertonic saline Decompressive craniectomy
ICP Monitoring n ICU patients who have sustained head trauma, brain hemorrhage, brain surgery, or conditions in which the brain may swell might require intracranial pressure monitoring. n The purpose of ICP monitoring is to continuously measure the pressure surrounding the brain.
Why Monitor? n n n Detect “events” Manage intracranial pressure Manage cerebral perfusion pressure
How? n n Ventriculostomy Intraparenchymal fiberoptic catheter Subarachnoid monitor Useful adjuncts: q q q Arterial line Central venous line Foley catheter
Manipulation of ICP CSF n External drainage q q q therapeutic as well as diagnostic technical issues infectious issues
What to do with the information. . . n n Goal: adequate oxygen delivery to maintain the metabolic needs of the brain. Intracranial pressure <20 n Cerebral perfusion pressure >50 -70 mm Hg CPP=MAP-ICP
Indications for ICP monitoring n n Glasgow coma scale <8 Clinical or radiographic evidence of increased ICP Post-surgical removal of intracranial hematoma Less severe brain injury in the setting which requires deep sedation or anesthesia
Measure ICP Management of Raised ICP n First Line Rx Maintain CPP>70 mm Hg Raised ICP>25 mm Hg Ventricular Drain Raised ICP>25 mm Hg Normal Vent/Oxygenation Mannitol Sedation CT
Maintain CPP>70 mm Hg Management of Raised ICP n Second Line Rx Raised ICP>25 mm Hg Furosemide Chemical Paralysis CSF Removal Vasopressor Raised ICP>25 mm Hg Barbiturates Hyperventilation Monitor Sj. O 2
Nursing Process The Patient with Increased Intracranial Pressure
Assessment
n n History q Present Illness q Obtain Subjective Data Neurologic examination q Mental Status q LOC q Cranial Nerve Function q Cerebral Function (balance and coordination) q Reflexes q Motor and Sensory Function q Abnormal Respiratory Pattern
Nursing Diagnosis
n n n Ineffective airway clearance related to diminished protective reflexes Ineffective breathing patterns related to neurologic dysfunction 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
Planning and Goals
n n n Maintenance of patent airway Normalization of respiration Adequate cerebral tissue perfusion through reduction in ICP Restoration of fluid balance Absence of infection Absence of complication
Nursing Intervention
n n n Maintaining patent airway and adequate ventilation Monitor vital signs and neurochecks Maintain fluid balance Position client with head of the bed elevated 30 to 45 degrees and neck in neutral position Maintain a quiet environment Avoid use of restraints Prevent straining at stool Prevent excessive cough and vomiting Prevent complication of immobility Preventing infection Administer medication as ordered
Evaluation
n n n Maintained patent airway Attains optimal breathing pattern Attains desired fluid balance Infection prevented Complications prevented
- Slides: 38