BSN

1. INCREASED INTRACRANIAL
PRESSURE

2. Increased Intracranial Pressure
 A life threatening situation that results from an
increase in any or all of the three components
(brain tissue, blood, CSF) of the skull.
 Brain tissues (space-occupying lesions) e.g. tumor,
abscess, edema
 Blood supply – e.g. thrombosis, embolism, aneurysm,
A-V malformation
 CSF – e.g obstruction to the flow caused by a brain
tumor, overproduction of the CSF due to tumor in the
choroid plexus.
 Above the threshold of 20 mm Hg

3. CAUSES
 Head injury
 Brain tumor
 CVA (cerebrovascular accident)
 Hydrocephalus
 Cerebral edema
 Bleeding post surgery

4. Clinical Manifestations
1. Restlessness – initial sign of Increased ICP
2. Change in Level of consciousness
 Unconsciousness – abnormal state of complete or
partial unawareness of self or environment.
 Lethargic
 Drowsy
 Stupor
 Motor/sensory change
 Due to the affectation of ascending reticular activating
system (ARAS).

5. Clinical Manifestations
3. Changes in vital signs – caused by
increasing pressure on the thalamus,
hypothalamus, pons, & medulla.
 irregular respirations
 bradycardia with full & bounding pulse
 widening pulse pressure
 ( CUSHING’S TRIAD)

6. Clinical Manifestations
4. Headache & irritability
5. Nausea & vomiting (projectile)
6. Pupillary Changes (Ocular signs)
 brisk constriction – normal reaction
 Anisocoria (inequality in the size of the pupil) due to CN
III compression. There is ipsilateral pupil dilatation.
 Sluggish reaction - indicates early pressure on cranial
nerve III.
 Fixed pupil – no response to light stimulus, indicates
uncal herniation. This causes compression of the
brainstem that results to respiratory arrest.
 Pinpoint pupils – indicate pons involvement

7. Clinical Manifestations
6. Decrease in motor function
 Hemiparesis or hemiplegia
 Decorticate & decerebrate posturing
•Inability to move the eye upward
•Ptosis of the eyelid
•Papilledema – (choked disk) swelling &
protrusion of the blind spot of the eye caused
by edema & compression of the optic nerve.

8.  A. Decorticate response –
flexion of arms,wrists,& fingers
with adduction in upper
extremities. Extension, internal
rotation, & plantar flexion in
lower extremities.
 B. Decerebrate response – all
four extremities in rigid
extension, with hyperpronation
of forearms & plantar flexion of
feet.
 C. Decorticate response on
right side of the body &
decerebrate response on the
left
 D. Opisthotonic posturing

12. Complications
 Cerebral perfusion
 Cerebral herniation
 SIADH
 Diabetes Insipidus

13. Diagnostic Studies
 MRI
 CT Scan
 Cerebral angiography
 EEG
 ICP Measurement
 PET

14. Nursing Diagnosis
 Ineffective airway clearance r/t ↓ LOC,
immobility, & inability to mobilize
secretions as manifested by ineffective
cough, inability to clear secretions,
crackles on auscultation, thick secretions
 Ineffective tissue perfusion (cerebral) r/t
cerebral edema as manifested by GCS <8,
agitation,  systolic BP, bradycardia, &
widened pulse pressure, ICP >20mmHg

15. Nursing Diagnosis
 Self-care deficit r/t altered LOC as
manifested by inability to follow commands
or move purposively, inability to perform
ADLs.
 Interrupted family processes

16. Planning
 Have ICP within normal limits
 Maintain a patent airway
 Demonstrate normal fluid & electrolyte
balance
 Have no complications secondary to
immobility & decreased LOC

17. Nursing Management
 Monitor v/s / “Neuro-checks”
 Maintain patent airway ( lying on one side with
frequent position changes, suctioning, oral
airway)
 Control HTN ( it reduces cerebral tissue
perfusion
 Keep head of bed elevated 30-45 degrees
 It promotes drainage of CSF from the subarachnoid
space of the brain
 It also promote maximum lung expansion

18. Nursing Management
 Avoid factors that increase ICP
 Nausea & vomiting
 Sneezing & coughing
 Valsalva maneuver, e.g. straining at stool
 Over suctioning
 Restraints
 Rectal examination
 Enema
 Flexion of waist, hip neck ( bending or stooping)
 Abdominal distention (NGT)

19. Nursing Management
 ABG monitoring
 Fluid & electrolyte balance
 IVF monitoring, restrict fluid intake 1,200 to 1,500
ml/day to reduce CSF production
 Electrolyte determinations (serum glucose, sodium,
potassium & osmolality)
 Urinary output is monitored to detect problems
related to diabetes insipidus (  uo related to ↓ in
antidiuretic hormone secretion.
 SIADH (syndrome of inappropriate antidiuretic
hormone), which results in ↓ in urinary output.

20. Nursing Management
 Monitoring intracranial pressure
 Ventriculostomy – the “gold standard” for
monitoring ICP whereby a catheter is inserted
into the lateral ventricle & coupled to an
external transducer.
 Consider infection

22. Special Consideration
 ICP should be measured as a mean
pressure at the end of expiration.
 If a CSF drainage device is in place, the
drain must be closed for at least 6
minutes to ensure an accurate reading
 The waveform strip should be recorded
along with other pressure monitoring
waveforms

23. Factors Affecting ICP readings
 CSF leaks around the monitoring device
 Obstruction of the intraventricular catheter
or bolt (from tissue or blood clot)
 Difference between the height of the bolt &
the transducer
 Kinks in the tubing
 In fluid coupled systems, bubbles or air in
the tubing also dampens the waveform

25. Normal ICP Waveforms
P1 – percussion wave – represents arterial
pulsations
P2 – rebound wave – reflects intracranial
compliance
P3 – dicrotic wave – follows dicrotic notch;
represents venous pulsations

26. Normal ICP Waveform

27. Abnormal ICP waveform indicating
high pressure & noncompliant brain

28. Pathologic ICP waveforms
A (plateau) waves indicate sharp increase in ICP, B waves
often precede A waves & C waves are related to normal
fluctuations in resp. & BP

29. Drug Therapy
 Mannitol – osmotic diuretics, most widely used
agent & is given IV.
 Decrease ICP in two ways:
1. Plasma expansion- there is an immediate plasma-
expanding effect that reduces the hematocrit & blood
viscosity, thereby increasing CBF (cerebral blood
flow) & cerebral oxygen delivery.
2. Osmotic effect – fluid moves from the tissues into the
blood vessels, therefore the ICP is reduced by a
decrease in the total brain fluid content
• Contraindicated if renal disease is present & if serum
osmolality is elevated.
• Check hourly urine output & BP

30. Loop diuretics
 Furosemide (Lasix), Bumetanide (Bumex),
Ethacrynic acid (Edecrin)
 Inhibit sodium & chloride reabsorption in the
ascending limb of the loop of Henle & thus
reduce blood volume & ultimately tissue volume.
 Also cause a reduction in the rate of CSF
production.
 Normal CSF production (adult) 20 to 30ml/hour
 Total CSF volume 90 to 150ml within the ventricles &
subarachnoid space

31. Corticosteroids
 E.g Dexamethasone (decadron)
 Thought to control the vasogenic edema
surrounding tumors & abscesses but appear to
have limited value in management of head-
injured patients.
 It reduces cerebral edema by its anti-
inflammatory effect.
 The only corticosteroid that can pass through the
blood-brain barriers.
 S/E: hyperglycemia, increased incidence of
infections, gastrointestinal (GI) bleeding &
hyponatremia

32. Barbiturates
 Pentobarbital (Nembutol, Thiopental
(Penthotal)
 Produce a decrease in cerebral
metabolism & subsequent decrease in ICP
 Secondary effect is a reduction in cerebral
edema & production of a more uniform
blood supply to the brain

33. Antiseizure drugs
 Valium (Diazepam)
 Phenytoin Sodium (Dilantin)
 Administer after meals if given p.o. to prevent GI upset
 Prepare 10 ml NSS to flush the IV line before & after
administration, it crystallizes in the vein
 Side effects:
 Gum hyperplasia – provide good oral care, use soft-bristled
toothbrush, massage the gums
 Sedation
 Hirsutism
 Ataxia
 Nystagmus
 GI upset
 aplastic anemia
 Reddish urine

34.  Phenobarbital (Na Luminal)
 Side effects:
 Sedation in adults
 Paradoxical active reaction in children
 Habituation
 Tegretol (Carbamazepine)
 Side effects: rash, ataxia, drowsiness

35.  Antacids to prevent GI irritation which may
be induced by dexamethasone
 Histamine-H2 receptor antagonists to
prevent stress ulcer
 Anticoagulants to prevent
thromboembolism
 NOTE: Opiates & sedatives are
contraindicated because they cause
respiratory depression & acidosis

36. THANK YOU!
Melania silva-banaticla,
rn,man

37. HEAD INJURY
 includes any trauma to the scalp, skull, or
brain.
 The term “Head Trauma” is used primarily to
signify craniocerebral trauma, which includes an
alteration in consciousness, no matter how brief.
 Has high potential for poor outcome
 Deaths occur at 3 time points after injury:
immediately after injury, 2 hours after injury &
approximately 3 weeks after injury.

38. Factors that predict poor outcome
 Presence of intracranial hematoma
 Increasing age of the patient
 Abnormal motor responses
 Impaired or absent eye movements or pupil light
reflexes
 Early sustained hypotension
 Hypoxemia or hypercapnia (presence of high
CO2 in the blood)
 ICP levels higher than 20mmHg

39. Etiology
A. Blunt
 Motor vehicle collision
 Pedestrian event
 Fall
 Assault
 Sports injury
B. Penetrating
 Gunshot wound
 arrow

40. Types of head injuries
1. Scalp Lacerations – most minor type of
head trauma.
 Associated with profuse bleeding
because the scalp contains many blood
vessels with poor constrictive abilities
 Infection is the major complication

41. Types of head injuries
2. Skull Fractures
 linear or depressed
 Simple, comminuted or compound
 Closed or open
 Type & severity depend on the velocity,
momentum, the direction of injuring agent, &
the site of impact.

42. Major potential complication of skull
fracture
 Intracranial infections
 Hematoma
 Meningeal & brain tissue damage

43. Types of Brain Injury
A. Concussion – injury is a temporary loss
of neurologic function with no apparent
structural damage
- May have period of unconsciousness
lasting for a few seconds or minutes
- Observe patient for headache, dizziness
, lethargy, irritability and anxiety

44. Types of Brain Injury
B. Contusion – bruising of the brain tissue
within a focal area that maintains the
integrity of the pia mater & arachnoid
layers.
 A structural alteration characterized by
extravasation of blood cells.
 Seizures are a common complication

45. Types of Brain Injury
C. Laceration – tearing of tissues caused by
a sharp fragment or object or a shearing
force.
 Hemorrhage is a serious complication, that
may cause:
 Epidural hematoma – bleeding between the dura & the
inner surface of the skull.
 Subdural hematoma – bleeding between the dura matter
& the arachnoid layer of the meningeal covering of the
brain.
 Intracerebral or subarachnoid hemorrhage

46. a. epidural hematoma
b. subdural hematoma

47. Types of Brain Injury
D. Compression of the Brain – results from
depressed fracture causing edema &
hemorrhage

48. ASSESSMENT
 S/Sx of increased ICP
 CSF leakage from ears & nose
 Battle’s sign ( hematoma at the mastoid
process) in basilar head trauma

49. Battle’s sign

51. Collaborative Management
 Care of the client with increased ICP
 Monitor for s/sx of meningitis, atelectasis,
pneumonia, UTI
 Monitor drainage from ears & nose.
 Two methods of testing:
 1. test the leaking fluid with a Dextrostix or Tes-
Tape to determine the presence of glucose, CSF
gives a positive reading for glucose.
 2. “halo” or “ring” sign

52. Nursing Diagnosis
 Ineffective Tissue Perfusion (cerebral) r/t
interruption of CBF associated with
cerebral hemorrhage, hematoma, &
edema.
 Hyperthermia r/t  metabolism, infection, &
loss of cerebral integrative function
secondary to possible hypothalamic injury.
 Acute pain (headache) r/t trauma &
cerebral edema

53. Nursing Diagnosis
 Impaired physical mobility r/t ↓ LOC &
treatment-imposed bed rest.
 Anxiety r/t abrupt change in health status,
hospital environment, & uncertain future
 Potential complication:  ICP r/t cerebral
edema & hemorrhage

54. Planning
 Maintain adequate cerebral perfusion
 Remain normothermic
 Be free from pain, discomfort & infection
 Attain maximal cognitive, motor & sensory
function

55. Interventions (emergency
management)
 Initial
 Ensure patent airway
 Stabilize cervical spine
 Administer O2 via nasal cannula
 Establish IV access
 Control external bleeding with sterile pressure
dressing
 Assess for rhinorrhea, otorrhea, scalp wounds
 Remove patient’s clothing

56. Interventions (emergency
management)
 Ongoing Monitoring
 Maintain patient warmth using blankets, lights,
warm IV fluids, warm humidified O2
 Monitor v/s, LOC, O2 Sat, cardiac rhythm,
GCS score, pupil size & reactivity.
 Anticipate need for intubation if gag reflex is
absent
 Assume neck injury with head injury
 Administer fluids cautiously to prevent fluid
overload &  ICP.

57. Thank you!