NUR 211 Increased Intracranial Pressure (IICP) #1 PDF

NUR 211, Fall 2023 Unit 3 Colleen Bastiani, MSN, RN **Increased Intracranial Pressure (IICP) \#1** **IGGY** pp 912-922 & **PERRY** pp 1378-1385 Mon 8/28/2023 +-----------------------------------+-----------------------------------+ | **What makes up the cranial | **Three parts of cranial...

NUR 211, Fall 2023 Unit 3 Colleen Bastiani, MSN, RN **Increased Intracranial Pressure (IICP) \#1** **IGGY** pp 912-922 & **PERRY** pp 1378-1385 Mon 8/28/2023 +-----------------------------------+-----------------------------------+ | **What makes up the cranial | **Three parts of cranial | | cavity?** | cavity:** | | | | | - ICP | 1. Brain \~80% | | | | | - CPP | 2. Cerebrospinal Fluid (CSF) \~ | | | 10% | | | | | | 3. Blood \~ 10% | | | | | | Adult - Rigid skull | | | | | | Children: | | | | | | - Open fontanels & sutures | | | allow for some skull | | | expansion | | | | | | - Have not fused together yet. | | | | | | - Measure HC & VS | | | | | | - HC = Mark spots with | | | Sharpie on head; measure | | | per agency protocol | | | | | | **Intra Cranial Pressure**: | | | | | | - ADULT | | | | | | - Normal = 10 -- 15 mmHg | | | | | | - Sustained ICP \>20 mmHg | | | for \>5 min = neurons die | | | → **Need to intervene** | | | | | | | | | | | | - PEDS -- Normal values: | | | | | | - Infant \< 1.5 mmHg | | | | | | - Younger child (3-9yo) \< | | | 3-7 mmHg | | | | | | - Older child \< 10mmHg | | | | | | **Cerebral Perfusion Pressure:** | | | | | | - **Calculate: MAP** (90 - | | | normal) -- **ICP** (10 - | | | normal) = 80 mmHg | | | | | | - ADULT: | | | | | | - Normal 70-90 mmHg | | | | | | - Post-TBI → Keep 60-70 | | | | | | - PEDS: | | | | | | - Infant \>40 mmHg | | | | | | - Limited data for normal | | | children's parameters | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **ETIOLOGY -** | Anything that increases the | | | contents in the cranium raises | | **What causes Increased | the pressure: | | Intracranial Pressure (IICP)?** | | | | - Brain tumors | | | | | | - Intracranial hemorrhage | | | (bleeding) | | | | | | - Hydrocephalus \-- | | | Accumulation of cerebral | | | spinal fluid (CSF) in | | | ventricles | | | | | | - Cerebral edema (brain | | | swelling) | | | | | | - Stroke (edema or bleeding) | | | | | | - TBIs (traumatic brain injury) | | | → edema, foreign material | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **ETIOLOGY -** |  | | | | | **What causes Increased | | | Intracranial Pressure (IICP)?** | | +===================================+===================================+ | **PATHOPHYSIOLOGY** | **Monro-Kellie hypothesis = ↑ in | | | one compartment causes ↓ in the | | | others to maintain normal cranial | | | pressure.** | | | | | | 1. Body's 1^st^ response to IICP | | | is to: | | | | | | a. Shunt **CSF** out | | | | | | b. Absorb it faster, or | | | | | | c. Make less | | | | | | 2. 15 - 20 % **Cardiac Output** | | | goes to the brain | | | | | | a. **↑** arterial pressure → | | | **vasoconstriction** in | | | arteries to the brain + | | | venous blood will move | | | into sinuses or jugular | | | veins. | | | | | | b. **↓** arterial pressure → | | | **vasodilation** in | | | vessels to the brain | | | | | | 3. Chemical Autoregulation | | | | | | i. Increased CO2 & H+ = | | | vasodilation | | | | | | ii. Decreased CO2 & H+ = | | | vasoconstriction, so RT | | | will cause | | | hyperventilation to drop | | | CO2 which causes | | | vasoconstriction and | | | decreases IICP | | | | | | 4\) Infants brain with open | | | fontanels will bulge to | | | compensate plus the normal | | | compensatory mechanisms. | | | | | | 5\) When Increased Intracranial | | | Pressure (IICP) develops there | | | is a decrease in blood | | | flow/perfusion to the brain | | | causing brain ischemia and | | | edema then if untreated brain | | | herniation and irreversible | | | damage | | | | | | 6\) IICP is \#1 cause of death | | | in head trauma victims that | | | arrive alive at hospital!!! | | | | | | - What does this mean for | | | nurses? | +-----------------------------------+-----------------------------------+ | **Assessment: Noticing** | **MIND CRUSHED**: | | | | | | **M**ental Status changes- | | | (**FIRST SYMPTOM)** restless, | | | confused, problems doing normal | | | tasks | | | | | | **I**rregular Breathing- | | | decreased RR and irregular then | | | hyperventilation then apneic | | | (late)=Cheyne Stokes | | | | | | **N**erve changes to optic and | | | oculomotor nerve-double vision, | | | papilledema(optic nerve | | | swelling), pupil changes(all), | | | abnormal dolls eyes=move head | | | side to side eyes stay | | | midline=brain stem herniation | | | | | | **D**ecorticate or Decerebrate | | | posturing | | | | | | **C**ushing's Triad (LATE | | | SIGN)-Increased SBP, decreased | | | pulse, abnormal RR | | | | | | **R**eflex positive Babinski = | | | toes fan instead of curl | | | | | | **U**nconscious (LATE SIGN) | | | | | | **S**eizures | | | | | | **H**eadache | | | | | | **E**mesis (vomiting) --without | | | nausea | | | | | | **D**eterioration of motor | | | function (hemiplegia) | +-----------------------------------+-----------------------------------+ | **Assessment: Noticing** | Most Common S/S=Headache, Nausea | | | and vomiting and Altered Mental | | MUST KNOW | Status/LOC | +-----------------------------------+-----------------------------------+ | **Neuro Exam-posturing** | Decorticate | | | = Flexion | | | | | | Decerebrate = Extension | +-----------------------------------+-----------------------------------+ | Level of Consciousness |  | +-----------------------------------+-----------------------------------+ | Glasgow Coma Scale | | | | | | **MUST KNOW** | | +-----------------------------------+-----------------------------------+ | GCS - example | The nurse calls the client's name | | | and gets no response. The nurse | | | then compresses the client's nail | | | bed and the client opens his | | | eyes. \_\_\_\_\_\_\_\_\_\_\_\_ | | | | | | The client tells the nurse who he | | | is and demands to know where he | | | is and why he is here. | | | \_\_\_\_\_\_\_\_\_\_\_\_ | | | | | | The client does not squeeze the | | | nurses fingers when asked to | | | squeeze them and will not answer | | | what year it is and just keeps | | | talking about riding his bike. He | | | did pull away when the nurse | | | compressed his nail beds. | | | \_\_\_\_\_\_\_\_\_\_ | | | | | | Total:\_\_\_\_\_\_\_\_\_\_\_\_ | | | | | | What does that mean? | | | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | | | _\_\_ | +-----------------------------------+-----------------------------------+ | **Pediatric Glasgow Coma Scale |  | | (GCS)** | | +-----------------------------------+-----------------------------------+ | Peds GCS - Example | The nurse enters the room and the | | | 10 month old is wide eyed looking | | | around the room. | | | \_\_\_\_\_\_\_\_\_\_\_\_ | | | | | | The 10 month old is flinging her | | | arms and legs and clenching her | | | fists. \_\_\_\_\_\_\_\_\_\_\_\_ | | | | | | The baby has not stopped crying | | | and screaming for the last hour. | | | Nothing helps: not food, not | | | holding, not toys. | | | \_\_\_\_\_\_\_\_\_\_ | | | | | | Total:\_\_\_\_\_\_\_\_\_\_\_\_ | | | | | | What does that mean? | | | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | | | _\_\_ | +-----------------------------------+-----------------------------------+ | **Monitor Intracranial Pressure | | | (ICP)** | | +-----------------------------------+-----------------------------------+ | Interventions | **PRESSURE: mnemonic** | | | | | DO NOT put in Trendelenberg | **P**osition HOB at 30-45 | | | degrees, with proper alignment of | | | head and No neck flexion | | | | | | **R**espiratory: prevent hypoxia | | | and hypercapnia = vasodilation | | | | | | **E**levated temperatures= | | | PREVENT THIS! Pt with ICP and | | | with an infection can get a | | | fever, it will also lead to | | | seizures, want to get TYLENOL on | | | board, neuro checks, glasgow coma | | | scale, ICP (only see in ICU) | | | | | | **S**ystems to monitor: GCS, | | | neuro checks per protocol, | | | monitor ICP levels-if greater | | | than 20 mmHg CALL HCP | | | | | | **S**training = avoid!, keep | | | stimuli to a minimum, low lights, | | | **Do NOT CLUSTER CARE. Do one | | | task at a time, if pt has to be | | | in low lights, and have to put on | | | sterile gloves on, place a towel | | | over their eyes and then turn on | | | the light** | | | | | | **U**nconscious patient care: | | | talk to them, hearing is the last | | | things that goes, | | | | | | **R**x: 1. barbiturates to | | | decrease brain metabolism and BP | | | thus decreasing ICP, 2 | | | vasopressors/IVF(3% NS) to keep | | | SBP 90-150, 3. anticonvulsants, | | | hyperosmotic drugs: 3% NS can | | | only be given in certain amounts, | | | can give it because it is neuro | | | protective | | | | | | **E**dema management: Mannitol, | | | Loop diuretics, | | | Corticosteroids(brain tumors not | | | trauma),not altering the kidney | | | function can lead to AKI, look at | | | BUN and Creatinine | | | | | | S/E corticosteroids: agitation, | | | don't want to increase the ICP | +-----------------------------------+-----------------------------------+