This document discusses increased intracranial pressure (ICP), its causes, diagnostic tools, and nursing care. It describes the Monro-Kellie hypothesis where the skull has a fixed volume, so an increase in one component (blood, CSF, brain tissue) increases pressure. Common causes of elevated ICP are head injuries, brain tumors, and hemorrhages. Diagnostic tools include CT, MRI, angiography and Doppler which can detect abnormalities that may cause increased pressure. Nursing care focuses on maintaining airway, respiration, fluid balance, reducing risk of infection, and preventing complications from immobility.

1. Medical Surgical Nursing

2. Increase Intracranial Pressure

4. Brain Brain tissue (1,400g) Blood (75mL) CSF (75mL) Normal ICP 10 to 20 mmHg

5. Monro-Kellie Hypothesis Limited space for expansion in the skull, an increase in anyone of the components causes a change in the volume of the others.

6. Pathophysiology

7. 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.

8. Elevated ICP most commonly associated with head injury Secondary Effects Brain tumors Subarachnoid hemorrhage Toxic and viral encephalities

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

10. Diagnostic Findings

11. Cerebral Angiography Computed Tomography (CT) Scanning Magnetic Resonance Imaging (MRI) Positron Emission Tomography (PET) Transcranial Doppler

12. Cerebral Angiography 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

13. Computed Tomography Scanning 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

14. Magnetic Resonance Imaging The first image shows normal MRI result The second image shows with brain tumor that causes increase ICP

15. Positron Emission Tomography The first image shows normal PET result The second image shows with brain tumor that may lead to increase ICP

16. Transcranial Doppler 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

17. Nursing Process The Patient with Increased Intracranial Pressure

18. Assessment

19. History Present Illness Obtain Subjective Data Neurologic examination Mental Status LOC Cranial Nerve Function Cerebral Function (balance and coordination) Reflexes Motor and Sensory Function Abnormal Respiratory Pattern

20. Nursing Diagnosis

21. 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

22. Planning and Goals

23. 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

24. Nursing Intervention

25. 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

26. Evaluation

27. Maintained patent airway Attains optimal breathing pattern Attains desired fluid balance Infection prevented Complications prevented