Intracranial pressure

1. Nursing Management of
Intracranial Pressure
Presented By:
Mr. TAUQEER AHMED, Sr. Lecturer
(FUCN)
Dated: 11/10/22
AHN-II
BSN Year-II SEMESTER-IV

2. Objectives
By the end of this lecture, students will be able to:
Review the basic anatomy & physiology of
Brain/spinal cord and CSF
Understand the mechanism of CSF production
and regulation
Discuss the causes of ICP
Know the signs and symptoms owing to ICP
Discuss the Nursing interventions to manage
the ICP

3. Intracranial Pressure
• Refers to the pressure contained within the
cranial cavity.
• The normal range is between 0 to 15 mmHg.
• ICP over 20 mm/Hg is considered elevated ICP,
also known as intracranial hypertension.
• The management team becomes concerned
whenever a patient’s ICP is over 15 mm/Hg,
but is especially concerned when it reaches
levels of intracranial hypertension.

4. Intracranial Pressure
• Skull has three essential components:
- Brain tissue = 78%
- Blood = 12%
- Cerebrospinal fluid (CSF) = 10%
• Any increase in any of these tissues
causes increased ICP

5. Components of the Brain
Fig. 55-1

6. Factors that influence ICP
1. Arterial pressure
2. Venous pressure
3. Intraabdominal and intrathoracic pressure
4. Posture
5. Temperature
6. Blood gases (CO2 levels)

7. Intracranial Pressure
• The degree to which these factors  ICP
depends on the ability of the brain to
accommodate to the changes

8. Regulation and Maintenance for
ICP
– If the volume in any one of the components
(brain tissue, blood, and CSF)
– increases within the cranial vault and the
volume from another component is
displaced, the total intracranial volume will
not change

9. Intracranial Pressure
Regulation and Maintenance
• Normal compensatory adaptations
– Alteration of CSF absorption or
production
– Shunting of CSF into spinal
subarachnoid space
– Shunting of venous blood out of the
skull

10. Mechanisms of Increased ICP
• Causes
– Mass lesion
– Cerebral edema
– Head injury
– Brain inflammation
– Metabolic insult

11. Increased Intracranial Pressure
Mechanisms of Increased ICP
• Sustained increases in ICP result in
brainstem compression and herniation of
the brain from one compartment to
another

12. Increased Intracranial Pressure
Fig. 55-3

13. Herniation
Fig. 55-4

14. SITES FOR ICP MONITORING
1- Epidural
2- Subarachnoid
3- Intraventricular

15. ICP mentoring system

16. ICP mentoring system

17. Increased Intracranial Pressure
(ICP)
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 17
Fig. 57-6. Coronal section of brain showing potential sites for placement of ICP monitoring devices.

18. Increased Intracranial Pressure
(ICP)
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 18
Fig. 57-7. Intracranial pressure monitoring can be used to continuously measure ICP. The ICP tracing
shows normal, elevated, and plateau waves. At high ICP the P2 peak is higher than the P1 peak,
and the peaks become less distinct and plateau.

19. Increased Intracranial Pressure
(ICP)
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 19
Fig. 57-8. Ventriculostomy in place. CSF can be drained via a ventriculostomy when ICP exceeds the
upper pressure parameter set by the physician. Intermittent drainage involves opening the three-way
stopcock to allow CSF to flow into the drainage bag for brief periods (30 to 120 seconds) until the
pressure is below the upper pressure parameters. ICP, Intracranial pressure.

20. Increased Intracranial Pressure
(ICP)
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 20
Fig. 57-9. A, Leveling a ventriculostomy. B, CSF is drained into a drainage system.

21. Increased Intracranial Pressure
(ICP)
• Monitoring of ICP and Cerebral Oxygenation,
continued
– CSF drainage
– Cerebral oxygenation monitoring
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 21

22. Increased Intracranial Pressure
(ICP)
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 22
Fig. 57-10. The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial
bolt (A). The system measures oxygen in the brain (PbtO2), brain tissue temperature, and intracranial
pressure (ICP) (B).

23. Increased Intracranial Pressure
(ICP)
• Collaborative Care
– Drug therapy
– Nutritional therapy
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 23

24. Nursing Care: Assessment
• Change in level of consciousness
• Changes in vital signs (Cushing triad)
– Widening pulse pressure
– Tachy/Bradycardia
– Increased systolic BP
– Irregular respirations

25. Nursing Care: Assessment
• Ocular signs
• Decrease in motor strength and function
– Assess movement
– Assess response to stimuli
– Assess:
• Decerebrate posturing (extensor)
–Indicates more serious damage
• Decorticate posturing (flexor)

26. Decorticate and Decerebrate Posturing

27. Nursing Care: Assessment
• Headache
– Often continuous and worse in the
morning
• Vomiting
– Not preceded by nausea
– Projectile

28. Increased Intracranial Pressure
Collaborative Care
• Hyperventilation therapy: suctioning →
hyperventilate with 100% oxygen
• Adequate oxygenation
– PaO2 maintenance at 100 mm Hg or
greater
– ABG analysis guides the oxygen therapy
– May require mechanical ventilator

29. Increased Intracranial Pressure
Collaborative Care
• Drug therapy
– Mannitol
– Loop diuretics
– Corticosteroids
– Barbiturates
– Antiseizure drugs

30. Increased Intracranial Pressure
Collaborative Care
• Nutritional therapy
– Patient is in hypermetabolic and
hypercatabolic state
–  Need for glucose
– Keep patient normovolemic
• IV 0.45% or 0.9% sodium chloride

31. Increased Intracranial Pressure
Nursing Management
Overall goals:
• ICP WNL
• Maintain patent airway
• Normal fluid and electrolyte balance
• No complications secondary to immobility
• Respiratory function
• Fluid and electrolyte balance

32. Increased Intracranial Pressure
Nursing Management
Overall goals (cont’d)
• Body position maintained in head-up
position: elevate HOB 30°
• Protection from injury: positioning/turning
• Pain control
• Psychological considerations

33. References
•
The Glasgow Structured Approach to Assessment of the Glasgow Coma Scale. Royal College of
Physicians and Surgeons of Glasgow. Retrieved from: https://www.glasgowcomascale.org/what-is-
gcs/
Hussein, M., Zettel, S., Suykens, A. (2017).The ABCs of managing increased intracranial
pressure. Journal of Nursing Education and Practice, 7(4), 6-14.
• Levine, W., Allain, R., Alston, T., Dunn, P., Kwo, J., Rosow, C. (2010). Anesthesia for
neurosurgery. In SA LeGrand & M Szabo (8th ed), Clinical anesthesia procedures of the
Massachusetts General Hospital: 389-408.
Maiese, K. (2019). Brain Herniation. The Merck Manual Professional Edition. Retrieved
from: https://www.merckmanuals.com/professional/neurologic-disorders/coma-and-impaired-
consciousness/brain-herniation
Smith, E.R. and Amin-Hanjani, S. (2019) Evaluation and management of elevated intracranial
pressure in adults. UpToDate. Retrieved from: https://www.uptodate.com/contents/evaluation-and-
management-of-elevated-intracranial-pressure-in-adults
Thompson, H.J. (2012). Care of the Patient Undergoing Intracranial Pressure Monitoring/ External
Ventricular Drainage or Lumbar Drainage. AANN Clinical Practice Guideline Series. Retrieved
from: https://www.bmc.org/sites/default/files/Patient_Care/Specialty_Care/Stroke_and_Cerebrovasc
ular_Center/Medical_Professionals/Protocols/AANN%20Guideline%20caring%20for%20ICP%20
Monitor%20External%20Vent%20Drain%20or%20Lumbar%20Drainage.pdf