Acetate ICP

8/3/2019 Acetate ICP

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Management of Client with Neurologic Trauma

Anatomy of the cranium

There are various brain contents that are localized within a

rigid structure.

Cranium

The cranial vault contents include:

The brain

The cerebral spinal fluid

The cerebral blood

Cerebral Spinal Fluid (CSF)

150 cc in adults at all times

Children slightly less

Produced by choroid plexus 20 cc/hr or 500 cc/day

CSF is eliminated by being absorbed into venoussystem at the subarachnoid villi and jugular system

Cerebral blood and brain

Cerebral blood

Sum of blood in capillaries, veins, and arteries

Brain

80% of the total intracranial volume

All of these contents are maintained @ a balanced pressure

referred to as intracranial pressure (ICP)

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Increase Intracranial Pressure

Is the pressure exerted by the cranium on the brain

tissue, cerebrospinal fluid (CSF), and the brains

circulating blood volume

Constantly fluctuating in response to activities such as

exercise, coughing, straining, arterial pulsation, and

respiratory cycle

Measured in millimeters of mercury (mmHg)

At rest normally 7-15 mmHg for a supine adult

Monro-KellieDoctrine

The ICP within the skull is directly related to the volume of

the contents.

Defined as the Monro-Kellie Doctrine

This doctrine states that any increase in volume of the

contents within the brain must be met with a decrease

in the other cranial contents.

Monro-Kellie Doctrine

Vintracranialvault=Vbrain+Vblood +Vcsf

CAUSES OF INCREASE INTRACRANIAL PRESSURE

Causes of ICP include a rise in cerebrospinal fluid pressure,

increased pressure within the brain matter, bleeding intothe brain or fluid around the brain, or swelling within the

brain matter itself.

- Mass effect: such as brain tumor, infarction with edema,

contusions, subdural or epidural hematoma, or abscess all

tend to deform the adjacent brain.

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- Generalized brain swelling: acute liver failure, hypertensive

encephalopathy (tend to decrease the cerebral perfusion

pressure but with minimal shifts)

- Increase in venous pressure: heart failure, obstruction of

jugular veins, thrombosis

- Obstruction to CSF flow and/or absorption: hydrocephalus,

meningeal disease (infections)

An increase in intracranial pressure is a serious medical

problem. The pressure itself can damage the brain or spinal

cord by pressing on important brain structures and by

restricting blood flow into the brain.

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Subdural hematoma develops when blood vessels that are

located between the membranes covering the brain (the

meninges) leak blood after an injury to the head. This is a

serious condition since the increase in intracranial pressure

can cause damage to brain tissue and loss of brain function.

Elevation of ICP may be graded as follows:

Normal ICP 0 15mmHg

Mild Elevation 16 20 mmHg

Moderate Elevation 21 30 mmHg

Severe Elevation 31 40 mmHgVery Severe Elevation41 mmHg and above

PATHOPHYSIOLOGY:

Increased ICP is a syndrome that affects many patients with

acute neurologic conditions. An elevated ICP is most

commonly associated with head injury, secondary effect in

other conditions, such as brain tumors, subarachnoidhemorrhage, and toxic and viral encephalopathies.

Increased ICP from any cause decreases cerebral perfusion,

stimulates further swelling (edema), and shifts brain tissue

through openings in the rigid dura, resulting in brain

herniation (next slide), a frequently fatal event.

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Early Manifestation:

- Decreased level of consciousness

- Confusion

- Restlessness

- Lethargy

- Difficulty with memory and thinking

- Changes in vision

- Headache

Later Manifestation:

- Continued decrease in LOC (stuporous, comatose)

- Dilated pupils, no reaction to light

- Hemiplegia that progresses

- Vomiting

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- Hypethermia

- Bradycardia

Late Changes:

- Exhibits abnormal motor responses in the form ofdecorticate or decerebrate posture (coma)

- Decreased LOC with difficulty to arouse

- Pupils will unilaterally enlarged progressing to fixed and

dilated

- Speech absent with only moaning

- Respiration will be irregular advancing to hyperventilation

and respiratory arrest

- Loss of corneal and gag reflexes

- Positive Babinski reflex (abnormal reflex)

- Vital Signs will present the CUSHING TRIAD Hypertension,

bradycardia and widening pulse pressure

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Decorticate posture is an abnormal posturing in which a person is stiffwith bent arms, clenched fists, and legs held out straight. The arms arebent in toward the body and the wrists and fingers are bent and held on

the chest.Decerebrate posture is an abnormal body posture that involves the

arms and legs being held straight out, the toes being pointed downward,

and the head and neck being arched backwards. The muscles are

tightened and held rigidly.

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Assessment and Diagnostic Findings:

The patient may undergo cerebral angiography, computed

tomography (CT) scanning, or magnetic resonance imaging

(MRI).

Transcranial Doppler studies provide information about

cerebral blood flow. The patient with increased ICP may also

undergo electrophysiologic monitoring to monitor the

pressure (next slide).

Lumbar puncture is avoided in patients with increased ICP

because the sudden release of pressure can cause the brain

to herniate.

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Intracranial pressure monitoring is performed by inserting acatheter into the head with a sensing device to monitor the

pressure around the brain.

MEDICAL MANAGEMENT:

Increased ICP is a true emergency and must be treated

immediately through:

Invasive monitoring of ICP

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 anddrainage,

and to evaluate the effectiveness of treatment.

Decreasing cerebral edema:

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Osmotic diuretics (mannitol) may be given to

dehydrate the brain tissue and reduce cerebral

edema. They reduce the volume of brain and

extracellular fluid.

Corticosteroids (eg, dexamethasone) help reducecerebral edema when a brain tumor is the cause of

increased ICP.

Maintaining cerebral perfusion: The cardiac output may

be manipulated to provide adequate perfusion to the

brain.

Inotropic agents such as dobutamine hydrochlorideare used. The effectiveness of the cardiac output is

reflected in the cerebral perfusion pressure, which

is maintained at greater than 70 mm Hg. A lower

cerebral perfusion pressure indicates that the

cardiac output is insufficient to maintain adequate

cerebral perfusion.

Lowering the volume of CSF and cerebral blood: CSFdrainage is frequently performed because the removal

of CSF with a ventriculostomy drain may dramatically

reduce ICP and restore cerebral perfusion pressure.

Controlling fever: Preventing a temperature elevation is

critical because fever increases cerebral metabolism

and the rate at which cerebral edema forms.

Maintaining oxygenation:

Arterial blood gases must be monitored to ensure

that systemic oxygenation remains optimal.

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Hemoglobin saturation can also be optimized to

provide oxygen more efficiently at the cellular

level.

Reducing metabolic demands: Cellular metabolic

demands may be reduced through the administration ofhigh doses of barbiturates when the patient is

unresponsive to conventional treatment.

Nursing Process:

The Patient with Increased ICP

Assessment:

Obtain a history of events leading to the present illness;

it may be necessary to obtain this information from

significant others.

The neurologic examination should include an

evaluation of mental status, level of consciousness

(LOC), cranial nerve function, cerebellar function(balance and coordination), reflexes, and motor and

sensory function. Assessment of LOC includes eye

opening; verbal and motor responses; pupils (size,

equality, reaction to light).

Because the patient is critically ill, ongoing assessment

will be more focused, including pupil checks,

assessment of selected cranial nerves, frequentmeasurements of vital signs and intracranial pressure,

and use of the Glasgow Coma Scale.

GLASGOW COMA SCALE:

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The Glasgow Coma Scale is a tool for assessing a patients

LOC. Scores range from 3 (deep coma) to 15 (normal).

Glasgow Coma Scale

Eye opening response Spontaneous

4

To voice

To pain 2

None 1

Best verbal response Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

Best motor response Obeys command 6

Localizes pain 5

Withdraws 4

Flexion (decorticate) 3

Extension (decerebrate) 2

None 1

Total

Nursing Diagnoses:

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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

Planning and goals

Maintenance of a patent airway,

Normalization of respiration,

Adequate cerebral tissue perfusion through reduction in

ICP,

Nursing Interventions:

Maintaining patent airway.

Assess the patency of the airway.

Suction with care the secretions obstructing the

airway, because transient elevations of ICP occur

with suctioning.

The patient is hyperoxygenated before and after

suctioning to maintain adequate oxygenation.

Discourage coughing because it increases ICP.

Auscultate the lung fields at least every 8 hours to

determine the presence of abnormal breath

sounds.

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Elevate the head of the bed may aid in clearing

secretions as well as improving venous drainage of

the brain.

Achieving an adequate breathing pattern

Monitor the patient constantly for respiratory

irregularities. This includes Cheyne-Stokes

respirations (alternating periods of hyperpnea and

apnea) and hyperventilation (increased rate and

depth of breathing) (Next slide).

A neurologic observation record is maintained.

Repeated assessments of the patient are madefrequently to immediately note improvement or

deterioration.

In case of deterioration, preparations are made for

surgical intervention.

Optimizing cerebral tissue perfusion

Maintain head alignment and elevate head of bed30 degrees. The rationale is that hyperextension,

rotation, or hyperflexion of the neck causes

decreased venous return.

Avoid extreme hip flexion as this increases intra-

abdominal and intrathoracic pressures, leading to

rise in ICP.

Avoid the Valsalva maneuver (straining at stool) as

it raises ICP. Administer stool softeners as

prescribed. If appropriate, provide high fiber diet.

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Note abdominal distention. Avoid enemas and

cathartics (sorbitol, magnesium citrate, sodium

sulfate).

When moving or being turned in bed, instruct the

patient to exhale to avoid the Valsalva maneuver

If the patient is on mechanical ventilation,

preoxygenate and hyperventilate him, before

suction, using 100% oxygen on the ventilator.

Suctioning should not last longer than 15 seconds.

Avoid activities that raise ICP if possible. Space

nursing interventions; this may prevent transientincreases in ICP.

During nursing interventions, the ICP should not

rise above 25 mm Hg and should return to baseline

levels within 5 minutes. Patients with

Patients with the potential for a significant increase

in ICP should receive sedation or paralyzation

before initiation of many nursing activities.

Avoid emotional stress, frequent arousal from

sleep, and environmental stimuli (noise,

conversation).

Isometric muscle contractions (Pushing against an

immovable wall) are also contraindicated because

they raise the systemic blood pressure and hencethe ICP.

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