Nur 265 Exam 3 Study Guide: Increased ICP
and Brain Injury Management
,
, Nur 265 Exam 3 Study Guide
Increased ICP ( 939-940, chart 941)
• Normal ICP 10-15 mmHg , pressures >20 mmHg impair cerebral circulation
• IICP is leading cause of death from head trauma in pts who reach the hospital alive.
• Cerebral Perfusion Pressure (CPP) o Blood flow required to provide adequate oxygenation & glucose for
brain metabolism o Maintenance above 70 mmHg o CPP= MAP-ICP
▪ MAP= S MAP NEEDS TO BE ATLEAST 80
• Compensation
o First Response – CSF is shunted or displaced into the spine (compliance) o Next – Reduction of
blood volume in the brain (autoregulation)
o As ICP continues to increase cerebral perfusion decreases leading to brain tissue ischemia, edema,
vasodilation then acidosis which causes further increases ICP
o In edema remains untreated the brain may herniate into spinal canal – death from brain stem
compression
• Assessment Findings o Changes in LOC – First sign of IICP is declining LOC & includes restlessness or
confusion to Stuporous
▪ W/o glucose & 02, brain shuts down. Ex. Pt knew who you were in am & now don’t
remember
o Headache – Quite environment may have photophobia so keep room lights very low. o Change in
speech pattern – Aphasia, Slurred Speech
o Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify
Dr
▪ Normal is 6 mm. Getting better if going back toward normal from dilated or constricted
▪ Uneven pupils tx as IICP until proven otherwise; pinpoint - brain stem (pons) dysfunction
o Abnormal Posturing – Decorticate (flexion) or Decerebrate (extensor)
▪ Decorticate – arms drawn to core, legs straight
, ▪ Decerebrate – arms straight and stiff, pts rarely survive o
Hyperthermia – followed later by hypothermia
▪ When hypothermic – BE CONCERNED, pressure on hypothalamus located next to brain stem
o Cardiac & respiratory rate/rhythm changes
▪ Tachy first – Increased HR & RR before brady HR & RR
o N/V – Common in IICP
o Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia
▪ Late response & indicates severe IICP w/loss of autoregulation, Imminent death
▪ Systolic BP increases bc decreased blood flow to brain
▪ Pressure on Vagus nerve and brainstem = bradycardia
• Managing IICP o Elevate HOB 30-45 degrees (unless contraindicated)
▪ If hypotension, elevate HOB where CPP >70
o Maintain head in a midline neutral position
o Avoid sudden and acute hip or neck flexion during positioning – Log roll pt o
Avoid clustering of care (bath followed by linen change) o Coughing and
suctioning increase ICP
o Decrease cerebral edema – osmotic diuretics (mannitol) & fluid restriction
▪ Mannitol is hypertonic- pulling fluid into vascular space- will inc. fluid output & monitor BP
for HTN
▪ Furosemide used in adjunct to reduce incidence of rebound from mannitol. Helps reduce
edema & blood volume, decrease Na uptake by the brain, & decrease production of CSF at
choroid plexus.
o LOW CSF using intraventricular drain system
o Control fever w/antipyretics or cooling blanket – do not allow pt to shiver as
will increase ICP
▪ When febrile every cell in body needs more 02 and glucose o Oxygenation –
Hyperventilate on a vent to decrease CO2 which causes vasodilation o Reduce cellular
and Brain Injury Management
,
, Nur 265 Exam 3 Study Guide
Increased ICP ( 939-940, chart 941)
• Normal ICP 10-15 mmHg , pressures >20 mmHg impair cerebral circulation
• IICP is leading cause of death from head trauma in pts who reach the hospital alive.
• Cerebral Perfusion Pressure (CPP) o Blood flow required to provide adequate oxygenation & glucose for
brain metabolism o Maintenance above 70 mmHg o CPP= MAP-ICP
▪ MAP= S MAP NEEDS TO BE ATLEAST 80
• Compensation
o First Response – CSF is shunted or displaced into the spine (compliance) o Next – Reduction of
blood volume in the brain (autoregulation)
o As ICP continues to increase cerebral perfusion decreases leading to brain tissue ischemia, edema,
vasodilation then acidosis which causes further increases ICP
o In edema remains untreated the brain may herniate into spinal canal – death from brain stem
compression
• Assessment Findings o Changes in LOC – First sign of IICP is declining LOC & includes restlessness or
confusion to Stuporous
▪ W/o glucose & 02, brain shuts down. Ex. Pt knew who you were in am & now don’t
remember
o Headache – Quite environment may have photophobia so keep room lights very low. o Change in
speech pattern – Aphasia, Slurred Speech
o Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify
Dr
▪ Normal is 6 mm. Getting better if going back toward normal from dilated or constricted
▪ Uneven pupils tx as IICP until proven otherwise; pinpoint - brain stem (pons) dysfunction
o Abnormal Posturing – Decorticate (flexion) or Decerebrate (extensor)
▪ Decorticate – arms drawn to core, legs straight
, ▪ Decerebrate – arms straight and stiff, pts rarely survive o
Hyperthermia – followed later by hypothermia
▪ When hypothermic – BE CONCERNED, pressure on hypothalamus located next to brain stem
o Cardiac & respiratory rate/rhythm changes
▪ Tachy first – Increased HR & RR before brady HR & RR
o N/V – Common in IICP
o Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia
▪ Late response & indicates severe IICP w/loss of autoregulation, Imminent death
▪ Systolic BP increases bc decreased blood flow to brain
▪ Pressure on Vagus nerve and brainstem = bradycardia
• Managing IICP o Elevate HOB 30-45 degrees (unless contraindicated)
▪ If hypotension, elevate HOB where CPP >70
o Maintain head in a midline neutral position
o Avoid sudden and acute hip or neck flexion during positioning – Log roll pt o
Avoid clustering of care (bath followed by linen change) o Coughing and
suctioning increase ICP
o Decrease cerebral edema – osmotic diuretics (mannitol) & fluid restriction
▪ Mannitol is hypertonic- pulling fluid into vascular space- will inc. fluid output & monitor BP
for HTN
▪ Furosemide used in adjunct to reduce incidence of rebound from mannitol. Helps reduce
edema & blood volume, decrease Na uptake by the brain, & decrease production of CSF at
choroid plexus.
o LOW CSF using intraventricular drain system
o Control fever w/antipyretics or cooling blanket – do not allow pt to shiver as
will increase ICP
▪ When febrile every cell in body needs more 02 and glucose o Oxygenation –
Hyperventilate on a vent to decrease CO2 which causes vasodilation o Reduce cellular
