5.3 Increased Intracranial Pressure (ICP) and Diagnostic

Question 1

Increased ICP Early Signs

Answer 1

3 Components enclosed in the skull (brain, blood, cerebrospinal fluid) - Change in these components causes change in other’s due to compensation.

Infants
- HALLMARK SIGN - High-pitched cry (neurocry)
- Macewen’s (cracked-pot) sign - Brain, sutures, fontanels swell and bulge (can easily see suture lines and vasculature of skull)
- Setting Sun Sign - Eyes tilted downward due to pressure in brain pushing eyes
- Headache/Vomiting/Fatigue/Irritability

Older Children
- Extreme headaches (most common symptom) on awakening after lying flat

Question 2

ICP Late Signs

Answer 2

Changes in Vital Signs (Cushing’s Triad)
- Increase in systolic pressure but decrease in pulse/pressure. OPPOSITE OF SHOCK
- Bradycardia
- Cheyne Strokes Respirations
- Widened pulse pressure

Other Signs
- Papilledema (optic nerve swelling)
- Decreased consciousness (COMA)
- Lack of response to painful stimuli

Question 3

ICP Nursing Interventions

Answer 3

• Elevate HOB to 15-30 degrees to facilitate venous drainage
• Maintain head at midline (straight and not tilted) to avoid jugular compression
  (Use firm foam or sand bags)
• Turn every 2 hours to reduce pooling of secretions
• Foley catheter (especially when giving mannitol which decreases pressure in skull)
• Maintain hydration and nutrition (especially in COMA)

Question 4

Posture of Neurological Conditions

Answer 4

Decorticate
- Flexor (arms move inward like c)
- Issues with spinal tract or cerebral hemisphere

Decerebrate
- Extensor (arms move outward like e)
- Problems with midbrain or pons

Question 5

Diagnostics for Neurological Conditions

Answer 5

• Health History
• Physical Assessment to see clinical presentation
• CT/MRI to see brain abnormalities

Labs
- CBC
- Blood cultures (check for sepsis/infection)
- Electrolyte balance
- Clotting factors

• Lumbar Puncture (most common diagnostic tool to learn what is housed in the CSF - cerebrospinal fluid)
• Needle is inserted into L3-L4 or L4-L5 into subarachnoid space to drain some CSF
• Checking for RBC, WBC, glucose, protein, cultures.
• The process for this is similar to an epidural where it is drained from the lower back spine. Usually baby is curled forward.
• Important to note pain management for these lumbar punctures (use numbing creams like lidocaine or pre-medicate patients with Tylenol or sugar water)
• Patient can be sitting up or side lying but the back needs to be rounded.
• After collecting CSF, make sure you provide adequate pressure to puncture site to avoid CSF leakage. Patients should lie flat for 4-8 hours while you monitor for bleeding or infections.
• Infections are important to watch because there is a direct tract to spinal tract and brain.
• Leakage of CSF can lead to spinal headache.

Question 6

Late Signs of ICP

Answer 6

• Papilledema
• Respiratory Distress
• Deteriorating LOC
• Fixed Pupils
• Dilated Pupils

Question 7

ICP

Answer 7

• Manifests differently in pediatrics because open sutures can somewhat compensate for increased pressure

Symptoms
- Increased skull size, bulging fontanelles, extension of cranial veins, loss of memory/attention and nausea