The rigid cranial vault contains brain tissue (1,400 g), blood (75 mL), and CSF (75 mL) The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP. ICP is usually measured in the lateral ventricles; normal ICP is 10 to 20 mm Hg. Increased 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. Although an elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumours, subarachnoid haemorrhage, and toxic and viral encephalopathies

1. NURSING MANAGEMENT
OF THE CLIENT WITH
INCREASED INTRACRANIAL
PRESSURE (ICP)
MR.ANILKUMAR B R M.SC NURSING
LECTURER MEDICAL SURGICAL NURSING

2. • The rigid cranial vault contains brain tissue (1,400
g), blood (75 mL), and CSF (75 mL)
• The volume and pressure of these three
components are usually in a state of equilibrium
and produce the ICP.
•ICP is usually measured in the lateral ventricles;
normal ICP is 10 to 20 mm Hg.

3. THE RIGID CRANIAL VAULT

4. THE RIGID CRANIAL VAULT

5. THE MONRO-KELLIE HYPOTHESIS
•The Monro-Kellie hypothesis states that
because of the limited space for expansion
within the skull, an increase in any one of
the components causes a change in the
volume of the others.

6. THE MONRO-KELLIE HYPOTHESIS

7. ETIOLOGY
• Increased 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. Although an
elevated ICP is most commonly associated with head
injury, it also may be seen as a secondary effect in other
conditions, such as brain tumours, subarachnoid
haemorrhage, and toxic and viral encephalopathies.

9. CLINICAL MANIFESTATIONS
•When ICP increases to the point at which the
brain’s ability to adjust has reached its limits,
neural function is impaired; this may be manifested
by clinical changes first in LOC and later by
abnormal respiratory and vasomotor responses.

10. CLINICAL MANIFESTATIONS
• Any sudden change in the patient’s condition, such as
restlessness (without apparent cause), confusion, or
increasing drowsiness, has neurologic significance.
• As ICP increases, the patient becomes stuporous,
reacting only to loud auditory or painful stimuli. At
this stage, serious impairment of brain circulation is
probably taking place, and immediate intervention is
required.

11. CLINICAL MANIFESTATIONS
•As neurologic function deteriorates further, the
patient becomes comatose and exhibits abnormal
motor responses in the form of decortication,
decerebration, or flaccidity.
•When the coma is profound, with the pupils
dilated and fixed and respirations impaired, death
is usually inevitable.

12. DECORTICATION, DECEREBRATION POSTURE

13. OTHERS CLINICAL MANIFESTATIONS
1. Changes in LOC
2. Changes in vital signs
3. Pupillary changes (due to increased pressure on the optic
and oculomotor nerves
4. Headache is increasing in intensity and aggravated by
movements and straining.
5. Vomiting recurrent with little or nausea, esp. in early
morning.

14. CLINICAL MANIFESTATIONS
6. Papilledema from optic nerve compression.
7. Restlessness, headache, forced breathing pattern,
purposeless movements and mental cloudiness.
8. Seizures activity: focal or generalized
9. Decreased brain stem function (CN deficits such as loss
of control reflexes and ability to swallow.
10. Pathologic reflexes: Babinski, grasp, chewing, sucking.

15. ASSESSMENT AND DIAGNOSTIC FINDINGS
1. The diagnostic studies used to determine the underlying
cause of increased ICP .
2. Cerebral angiography
3. Computed tomography (CT) scanning
4. Magnetic resonance imaging (MRI) or positron emission
tomography (PET).
5. Transcranial Doppler studies provide information about
cerebral blood flow.

16. •Lumbar puncture is avoided in patients with
increased ICP because the sudden release of
pressure can cause the brain to herniate.

17. COMPLICATIONS
1. Complications of increased ICP include brain stem
herniation
2. Diabetes insipidus syndrome
3. Inappropriate antidiuretic hormone (SIADH)
4. Brain stem herniation results from an excessive increase
in ICP, when the pressure builds in the cranial vault and
the brain tissue presses down on the brain stem.

18. MANAGEMENT
• Increased ICP is a true emergency and must be treated
promptly.
• Invasive monitoring of ICP is an important component of
management, but immediate management to relieve
increased ICP involves decreasing cerebral edema,
lowering the volume of CSF, or decreasing cerebral blood
volume while maintaining cerebral perfusion.

19. • These goals are accomplished by:
1. Administering osmotic diuretics and corticosteroids
2. Restricting fluids, draining CSF.
3. Controlling fever maintaining systemic blood pressure
and oxygenation, and reducing cellular metabolic
demands.

20. MONITORING ICP
•The purposes of ICP monitoring are to identify
increased pressure early in its course (before
cerebral damage occurs), to quantify the degree
of elevation, to initiate appropriate treatment, to
provide access to CSF for sampling and drainage,
and to evaluate the effectiveness of treatment.

21. MONITORING ICP
•An intraventricular catheter
(ventriculostomy), a subarachnoid bolt, an
epidural or subdural catheter, or a fiberoptic
transducer-tipped catheter placed in the
subdural space or the ventricle can be used to
monitor ICP.

22. ICP MONITORING

23. ICP MONITORING

24. ICP MONITORING

25. DECREASING CEREBRAL EDEMA
• Osmotic diuretics (mannitol) may be given to dehydrate
the brain tissue and reduce cerebral edema.
• They act by drawing water across intact membranes,
thereby reducing the volume of brain and extracellular
fluid.
• An indwelling urinary catheter is usually inserted to
monitor urinary output and to manage the resulting
diuresis.

26. OSMOTIC DIURETICS (MANNITOL

27. 1. Corticosteroids (e.g., dexamethasone) help
reduce the edema surrounding brain tumours
when a brain tumour is the cause of increased
ICP.
2. Another method for decreasing cerebral
edema is fluid restriction .

28. MAINTAINING CEREBRAL PERFUSION
• The cardiac output may be manipulated to provide
adequate perfusion to the brain.
• Improvements in cardiac output are made using fluid
volume and inotropic agents such as dobutamine
hydrochloride.
• The effectiveness of the cardiac output is reflected in the
cerebral perfusion pressure, which is maintained at
greater than 70 mm Hg.

29. DOBUTAMINE HYDROCHLORIDE.

30. REDUCING CSF AND INTRACRANIAL BLOOD
VOLUME
• CSF drainage is frequently performed because the
removal of CSF with a ventriculostomy drain may
dramatically reduce ICP and restore cerebral
perfusion pressure. Caution should be used in
draining CSF because excessive drainage may
result in collapse of the ventricles.

31. CONTROLLING FEVER
• Preventing a temperature elevation is critical
because fever increases cerebral metabolism
and the rate at which cerebral edema forms.
• Strategies to reduce temperature include
administration of antipyretic medications, as
prescribed, and use of a cooling blanket.

32. MAINTAINING OXYGENATION
• Arterial blood gases must be monitored to
ensure that systemic oxygenation remains
optimal.
• Hemoglobin saturation can also be optimized
to provide oxygen more efficiently at the
cellular level.

33. NURSING PROCESS: THE PATIENT WITH
INCREASED ICP
• The neurologic examination should be as complete as the patient’s
condition allows. It includes an evaluation of mental status, LOC,
cranial nerve function, cerebellar function (balance and
coordination), reflexes, and motor and sensory function.
• Ongoing assessment will be more focused, including pupil checks,
assessment of selected cranial nerves, frequent measurements of
vital signs and intracranial pressure, and use of the Glasgow Coma
Scale.

34. NURSING DIAGNOSIS
• Ineffective airway clearance related to diminished protective reflexes
(cough, gag)
• Ineffective breathing patterns related to neurologic dysfunction (brain
stem compression, structural displacement)
• 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 (fiberoptic or
intraventricular catheter)