Intracranial Pressure (ICP) and Brain Injury

• Normal intracranial pressure (ICP) in adults is 5-15 mmHg.
• Interventions are required when ICP is above 20 mmHg.

Monro-Kellie Hypothesis

• Brain tissue, blood, and cerebrospinal fluid (CSF) must maintain a balance within the skull because the skull is a fixed space.

Cushing’s Triad

• Cushing's Triad includes hypertension, bradycardia, and irregular respirations
• Tachycardia isn’t a component.
• Decerebrate posturing (rigid extension, pronated arms) indicates severe brainstem damage, which is more severe than decorticate posturing
• Normal cerebral perfusion pressure (CPP) range is 60-70 mmHg.
• CPP is calculated by MAP – ICP; and is needed for adequate brain perfusion.
• Increased ICP can lead to brain herniation by compressing brain structures.
• A Glasgow Coma Scale (GCS) score of ≤ 8 indicates a severe brain injury.
• Mannitol reduces cerebral edema by acting as an osmotic diuretic, drawing fluid out of the brain.
• If a patient has a head injury and an ICP of 25 mmHg, elevate the head of the bed to 30 degrees first.
• Elevating the HOB promotes venous drainage and helps lower ICP.
• Priority interventions for increased ICP include maintaining normothermia and administering Mannitol as prescribed.
• Fever can increase ICP.
• Frequent suctioning and supine positioning can also increase ICP.
• Brain herniation can present with fixed pupils, abnormal posturing, and Cushing's Triad.
• Sudden, unilateral pupil dilation in a patient with increased ICP indicates brainstem compression and impending herniation, requiring immediate intervention.
• Care plan interventions for a patient with a traumatic brain injury should include maintaining a quiet environment, monitoring for signs of Cushing's Triad, and elevating the HOB to 30 degrees.
• A subdural hematoma is most likely caused by venous bleeding between the dura and arachnoid layers, often due to trauma.
• The most appropriate positioning technique for a patient with increased ICP is supine with the head midline and slightly elevated (30 degrees) to promote venous drainage.
• Administer IV antibiotics as the priority intervention for suspected bacterial meningitis because it is life-threatening and requires immediate antibiotic therapy.
• Traumatic brain injury can damage the pituitary gland, leading to diabetes insipidus (DI), which causes polyuria and hypernatremia.
• Worsening condition in a patient with increased ICP is indicated by BP 180/60, HR 50, RR 8.
• This suggests Cushing's Triad, indicating brainstem compression and possible herniation.

Clinical Manifestations of a Basilar Skull Fracture

• Battle's sign (bruising behind the ear)
• Raccoon eyes (periorbital bruising)
• CSF leakage
• CT scans are preferred for quickly detecting hemorrhages and fractures in head trauma evaluations
• For a patient with increased ICP who suddenly becomes unresponsive with dilated pupils, the priority action is to prepare for emergency intubation because unresponsiveness with dilated pupils suggests brain herniation and requires immediate airway management.
• A statement that indicates understanding of concussion management is: "I should rest for 24-48 hours and gradually resume activities,"
• Cognitive and physical rest for 24-48 hours is recommended, followed by gradual activity resumption.
• If a patient with a VP shunt for hydrocephalus develops a fever and lethargy, shunt infection is suspected, requiring immediate medical intervention.
• If a patient with increased ICP is receiving hypertonic saline, intervention is required if the serum sodium is 158 mEq/L
• Hypertonic saline can cause hypernatremia, which may lead to seizures and neurological deterioration.
• Education plan includes avoiding alcohol consumption, reporting worsening symptoms
• Use helmets to help prevent further injuries
• Ensure they are cleared by a healthcare provider before resuming work
• Medical clearance is essential to ensure recovery and prevent complications.
• First action should be assessing for other signs of increased ICP
• Glasgow Coma Scale (GCS) score of ≤ 8 indicates a severe brain injury requiring intensive monitoring.
• Cushing's Triad (hypertension, bradycardia, irregular respirations) is a late sign of brain herniation, not an early one.
• An ICP reading of 35 mmHg requires immediate action
• 35 mmHg indicates a critical elevation requiring intervention.
• Avoid PaCO2 of 45-50 mmHg when using mechanical ventilation because high PaCO2 (above 45 mmHg) causes cerebral vasodilation, which increases ICP.
• A small amount of clear nasal drainage may indicate CSF leakage, increasing the risk of infection and brain herniation
• Mannitol is an osmotic diuretic that promotes diuresis, so urine output should be closely monitored to assess for dehydration and electrolyte imbalances.
• Interventions for TBI includes padding side rails, having suction ready, and minimizing stimuli reduce the risk of injury during a seizure.
• A nurse is teaching a family about signs of worsening ICP in a patient with a brain injury needs further teaching if they say "I don't need to stop smoking because I take aspirin."
• Educate patients should avoid contact sports, monitor for ICP symptoms, and prioritize rest to promote brain healing
• The first action when caring for a patient with bacterial meningitis is to place the patient in a private room because bacterial meningitis is highly contagious and requires droplet precautions before other interventions.
• Further teaching when teaching about stroke prevention is needed if they say "I don't need to stop smoking because I take aspirin."
• Family presence can help calm the patient. Benzodiazepines and restraints should be used cautiously as they may worsen ICP.
• Headache and vomiting may indicate shunt malfunction or increased ICP, requiring urgent evaluation.