Medical Surgical Nursing
Increase Intracranial Pressure
 
Brain <ul><li>Brain tissue (1,400g) </li></ul><ul><li>Blood (75mL) </li></ul><ul><li>CSF (75mL) </li></ul><ul><li>Normal I...
Monro-Kellie Hypothesis <ul><li>Limited space for expansion in the skull, an increase in anyone of the components causes a...
Pathophysiology
<ul><li>Increase ICP is a syndrome that affects many patients with acute neurologic conditions. This is because pathologic...
Elevated ICP most commonly associated with head injury <ul><li>Secondary Effects </li></ul><ul><ul><li>Brain tumors </li><...
Brain Tumor Decrease Cerebral Blood Flow Ischemia and Cell Death Early Cerebral Ischemia Vasomotor Stimulation (brainstem)...
Diagnostic Findings
<ul><li>Cerebral Angiography </li></ul><ul><li>Computed Tomography (CT) Scanning </li></ul><ul><li>Magnetic Resonance Imag...
Cerebral Angiography <ul><li>The first image shows normal brain blood flow </li></ul><ul><li>The second image shows presen...
Computed Tomography Scanning <ul><li>The first image shows a normal view of the brain </li></ul><ul><li>The second image s...
Magnetic Resonance Imaging <ul><li>The first image shows normal MRI result </li></ul><ul><li>The second image shows with b...
Positron Emission Tomography <ul><li>The first image shows normal PET result </li></ul><ul><li>The second image shows with...
Transcranial Doppler <ul><li>The top shows a TCD of a normal artery  </li></ul><ul><li>Bottom shows a severely stenosed in...
Nursing Process The Patient with Increased Intracranial Pressure
Assessment
<ul><li>History  </li></ul><ul><ul><li>Present Illness </li></ul></ul><ul><ul><li>Obtain Subjective Data </li></ul></ul><u...
Nursing Diagnosis
<ul><li>Ineffective airway clearance related to diminished protective reflexes </li></ul><ul><li>Ineffective breathing pat...
Planning and Goals
<ul><li>Maintenance of patent airway </li></ul><ul><li>Normalization of respiration </li></ul><ul><li>Adequate cerebral ti...
Nursing Intervention
<ul><li>Maintaining patent airway and adequate ventilation </li></ul><ul><li>Monitor vital signs and neurochecks </li></ul...
Evaluation
<ul><li>Maintained patent airway </li></ul><ul><li>Attains optimal breathing pattern </li></ul><ul><li>Attains desired flu...
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Increase Intracranial Pressure

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Increase Intracranial Pressure

  1. 1. Medical Surgical Nursing
  2. 2. Increase Intracranial Pressure
  3. 4. Brain <ul><li>Brain tissue (1,400g) </li></ul><ul><li>Blood (75mL) </li></ul><ul><li>CSF (75mL) </li></ul><ul><li>Normal ICP 10 to 20 mmHg </li></ul>
  4. 5. Monro-Kellie Hypothesis <ul><li>Limited space for expansion in the skull, an increase in anyone of the components causes a change in the volume of the others. </li></ul>
  5. 6. Pathophysiology
  6. 7. <ul><li>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. </li></ul>
  7. 8. Elevated ICP most commonly associated with head injury <ul><li>Secondary Effects </li></ul><ul><ul><li>Brain tumors </li></ul></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><ul><li>Toxic and viral encephalities </li></ul></ul>
  8. 9. 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
  9. 10. Diagnostic Findings
  10. 11. <ul><li>Cerebral Angiography </li></ul><ul><li>Computed Tomography (CT) Scanning </li></ul><ul><li>Magnetic Resonance Imaging (MRI) </li></ul><ul><li>Positron Emission Tomography (PET) </li></ul><ul><li>Transcranial Doppler </li></ul>
  11. 12. Cerebral Angiography <ul><li>The first image shows normal brain blood flow </li></ul><ul><li>The second image shows presence of cerebral aneurysm that can cause decease cerebral blood flow may lead to increase ICP </li></ul>
  12. 13. Computed Tomography Scanning <ul><li>The first image shows a normal view of the brain </li></ul><ul><li>The second image shows brain with tumor and edema that may lead to increase ICP </li></ul>
  13. 14. Magnetic Resonance Imaging <ul><li>The first image shows normal MRI result </li></ul><ul><li>The second image shows with brain tumor that causes increase ICP </li></ul>
  14. 15. Positron Emission Tomography <ul><li>The first image shows normal PET result </li></ul><ul><li>The second image shows with brain tumor that may lead to increase ICP </li></ul>
  15. 16. Transcranial Doppler <ul><li>The top shows a TCD of a normal artery </li></ul><ul><li>Bottom shows a severely stenosed internal carotid artery causes decrease cerebral blood flow may lead to increase ICP </li></ul>
  16. 17. Nursing Process The Patient with Increased Intracranial Pressure
  17. 18. Assessment
  18. 19. <ul><li>History </li></ul><ul><ul><li>Present Illness </li></ul></ul><ul><ul><li>Obtain Subjective Data </li></ul></ul><ul><li>Neurologic examination </li></ul><ul><ul><li>Mental Status </li></ul></ul><ul><ul><li>LOC </li></ul></ul><ul><ul><li>Cranial Nerve Function </li></ul></ul><ul><ul><li>Cerebral Function (balance and coordination) </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul><ul><ul><li>Motor and Sensory Function </li></ul></ul><ul><ul><li>Abnormal Respiratory Pattern </li></ul></ul>
  19. 20. Nursing Diagnosis
  20. 21. <ul><li>Ineffective airway clearance related to diminished protective reflexes </li></ul><ul><li>Ineffective breathing patterns related to neurologic dysfunction </li></ul><ul><li>Ineffective cerebral tissue perfusion related to the effects of increased ICP </li></ul><ul><li>Deficient fluid volume related to fluid restriction </li></ul><ul><li>Risk for infection related to ICP monitoring system </li></ul>
  21. 22. Planning and Goals
  22. 23. <ul><li>Maintenance of patent airway </li></ul><ul><li>Normalization of respiration </li></ul><ul><li>Adequate cerebral tissue perfusion through reduction in ICP </li></ul><ul><li>Restoration of fluid balance </li></ul><ul><li>Absence of infection </li></ul><ul><li>Absence of complication </li></ul>
  23. 24. Nursing Intervention
  24. 25. <ul><li>Maintaining patent airway and adequate ventilation </li></ul><ul><li>Monitor vital signs and neurochecks </li></ul><ul><li>Maintain fluid balance </li></ul><ul><li>Position client with head of the bed elevated 30 to 45 degrees and neck in neutral position </li></ul><ul><li>Maintain a quiet environment </li></ul><ul><li>Avoid use of restraints </li></ul><ul><li>Prevent straining at stool </li></ul><ul><li>Prevent excessive cough and vomiting </li></ul><ul><li>Prevent complication of immobility </li></ul><ul><li>Preventing infection </li></ul><ul><li>Administer medication as ordered </li></ul>
  25. 26. Evaluation
  26. 27. <ul><li>Maintained patent airway </li></ul><ul><li>Attains optimal breathing pattern </li></ul><ul><li>Attains desired fluid balance </li></ul><ul><li>Infection prevented </li></ul><ul><li>Complications prevented </li></ul>
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