Chapter 28: Increased Intracranial Pressure (ICP) (Children)

Question 1

Intracranial Pressure

Answer 1

is the pressure of the CSF in the subarachnoid space between the skull and the brain
-normal ICP= 0 to 10 mm Hg

Question 2

Increased Intracranial Pressure (ICP)

Answer 2

can lead to secondary (preventable) brain injury

• the cranium and vertebral body form a rigid container, and if any of its contents increase, an increase in ICP occurs
• as brain volume expands, some compensation is possible as CSF and blood move into the spinal canal and extracranial vasculature
• once ICP reaches 20 mm Hg, small increases in blood volume can result in extreme elevations of ICP
• infants and children whose fontanelles have not closed are able to compensate for increased ICP for a short time; the child’s fontanelles bulge, and cranial sutures may spread apart to accommodate the increased volume

Question 3

Monro-kellie Hypothesis

Answer 3

is the pressure-volume relationship among the blood, ICP, volume of CSF, brain tissue, and cerebral perfusion pressure
-states: if one of the components increases, the other components must compress. The body tries to compensate by an increase in CSF absorption, a decrease in CSF production, a reduction in blood volume, or a decrease in brain mass.
>When compression is exhausted, the ICP rises; as a result of increased ICP, blood flow and oxygen delivery may be compromised; when blood flow and oxygen decrease, secondary brain injury occurs

Question 4

Signs and Symptoms of Increased ICP

Answer 4

r/t to cerebral edema and ischemia

• change in LOC
• irritability
• lethargy
• headache
• nausea and emesis (important)
• diplopia and blurred vision
• seizures

Question 5

Early Signs and Symptoms of Increased ICP

Answer 5

• headache
• emesis
• change in LOC
• decrease in GCS score
• irritability
• sunsetting eyes
• decreased eye contact (infant)
• pupil dysfunction
• cranial nerve dysfunction
• seizures

Question 6

Late Signs and Symptoms of Increased ICP

Answer 6

• further decrease in LOC
• bulging fontanelles (infant)
• decreased spontaneous movements
• posturing
• papilledema (optic disk swelling)
• pupil dilation with decreased or no response to light
• increased blood pressure
• irregular respirations
• Cushing’s triad (late, ominous sign)

Question 7

Cushing’s Triad

Answer 7

late, ominous sign
-hypertension (with widening pulse pressure)
-bradycardia
-irregular respiratory pattern
>usually indicative of impending herniation (the displacement of the brain through the foramen magnum)

Question 8

Diagnosis

Answer 8

-signs + symptoms and diagnostic tests
-Papilledema (a mass of blown-out blood vessels located around the optic nerve) is important sign of increased ICP
>can be observed when the nurse assesses the child’s eyes with an ophthalmoscope
-MRI or CT is used to determine the etiology and severity of increased ICP; CT contrast is avoided in the presence of intracranial bleeding
-child’s ICP can also be monitored by inserting an intracranial catheter

Question 9

Papilledema

Answer 9

a mass of blown-out blood vessels located around the optic nerve

• important sign of increased ICP
• can be observed when the nurse assesses the child’s eyes with an ophthalmoscope

Question 10

Prevention

Answer 10

• safety and injury prevention
• educational strategies
• anticipatory guidance on safety issues

Question 11

Nursing Care

Answer 11

closely monitor the pediatric patient with increased ICP b/c changes in the neurological status can occur very quickly and may have life-threatening consequences
-supportive care and prevent secondary injury
-when caring for a child with an altered state of consciousness, carefully monitor the child’s neurological status by assessing LOC with the use of a pediatric Glasgow Coma Scale (GCS); consists of three components of assessment: eye opening, motor, and auditory/visual responses
-monitors, measures, and documents vital signs, LOC, reflexes, and pupil reaction; frequency of vital signs depends on the etiology, neurological status, and cerebral involvement
>any change in vital signs needs to be evaluated b/c the child’s condition can deteriorate rapidly

Question 12

Glasgow Coma Scale (GCS)

Answer 12

when caring for a child with an altered state of consciousness, carefully monitor the child’s neurological status by assessing LOC with the use of a pediatric Glasgow Coma Scale (GCS)
-three components: eye opening, motor, and auditory/visual responses
-nurse assigns a numeric value to each of the levels of response:
>9-15 (unaltered state of consciousness)
>8-4 (state of coma)
>3 or below (deep coma)
-coma scale scores may fluctuate if a change in neurological state occurs, including cerebral ischemia; the administration of medications (paralytics and sedatives); and a regaining of consciousness
-the child is intubated if the Glasgow Coma Score is less than 8

Question 13

Cerebral Infections: Elevated Temperature

Answer 13

can cause elevated temperatures; temperature measured every 2 to 4 hours
-antipyretics such as acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Advil) are administered by the nurse to lower the child’s temperature
>cooling the environment, applying a hypothermic blanket, or providing a tepid bath can also decrease body temperature

Question 14

Positioning of the Child to prevent jugular compression and facilitate venous drainage?

Answer 14

• head of bed elevated to 15 to 30 degrees

- child’s head maintained in a midline position

Question 15

How can you prevent development of contractures?

Answer 15

perform passive range-of-motion exercises at least every 2 hours

Question 16

Priority for any child with an alteration in consciousness

Answer 16

obtaining a patent airway

-inadequate oxygenation or excess carbon dioxide causes cerebral blood vessels to dilate, resulting in increased ICP

Question 17

Monitoring Respiratory Status

Answer 17

nurse meticulously assesses respiratory status
-respiratory rate and rhythm
-use of accessory muscles
-apnea
-breath sounds
-level of oxygenation
>a child in a light coma still may be able to cough and swallow and maintain adequate respiratory function; child in a deep coma may be unable to swallow or adequately handle oral secretions
-gag reflex of an unconscious child may be impaired; the airway must be suctioned to remove secretions that may obstruct the airway or be aspirated. Be careful when suctioning b/c ICP may increase

Question 18

Hyperventilation

Answer 18

if the child’s condition deteriorates, hyperventilation, with a bag valve mask (e.g. Ambu Resuscitator), may be performed until the ICP decreases
>hyperventilation aimed at keeping a low level of serum PCO2 so that cerebral blood flow decreases and reduces cerebral blood volume, reducing ICP
-prolonged hyperventilation is avoided b/c it may cause hypotension as a result of decreased venous return

Question 19

Mechanical Ventilation

Answer 19

a child who cannot maintain respiratory function needs to be mechanically ventilated
-may need for a short time or may be dependent indefinitely
-monitor arterial blood gases
-administer medications to sedate or relax the child to prevent injury r/t manipulation of the endotracheal tube or accidental extubating
>an unconscious child who is intubated for an extended period of time requires a tracheostomy; nurse performs tracheostomy care; changes child’s position every 2 hours and performs chest physiotherapy to prevent respiratory complications of atelectasis and pneumonia

Question 20

Assessing for Hypothermia

Answer 20

when using a hypothermic blanket, monitor the patient’s temperature to prevent hypothermia (a body temperature below 95 Degrees F)
-hypothermia causes shivering and increased ICP

Question 21

What takes Priority when a child has increased ICP and inadequate circulation?

Answer 21

fluid administration

• fluid restriction is contraindicated in children who are poorly perfused with brain pathology or are hypovolemic b/c hypovolemia results in decreased cerebral perfusion
• monitors fluid balance by measuring and recording intake and output

Question 22

The Child with Increased ICP is predisposed to what?

Answer 22

Seizures

• monitor seizures for such factors as frequency, severity, and type of seizure
• places child under seizure precautions; padded side rails or bed rails, oxygen and suction equipment readily available, IV access, and anticonvulsant medications at bedside

Question 23

Focus on Safety: Care Measures

Answer 23

• never place the patient’s head lower than the body
• administer IV fluid cautiously because hypertonic IV solutions have a osmotic effect; Normal saline, Lactated Ringers solution, and albumin are primarily used
• hypotonic IV fluids (a combination of dextrose [5-10%] and sodium chloride [o.22% or 0.3%]) are avoided b/c they cross the blood-brain barrier resulting in increased cerebral edema and ICP

Question 24

Medical Care

Answer 24

• anti-seizure medications (phenytoin [Dilantin]); controls seizures but may cause gingival hyperplasia
• mannitol (Osmitrol); administered to decrease cerebral edema
• barbiturates
• may require analgesia and sedation
• narcotics and benzodiazepines

Question 25

mannitol (Osmitrol)

Answer 25

> Classification: osmotic diuretic
Indications: reduction of intracranial pressure and treatment of cerebral edema
Actions: increases the osmolality of the glomerular filtrate, preventing the reabsorption of water and resulting in a loss of sodium chloride and water
Contraindications: hypersensitivity, anuria, and active intracranial bleeding
Side Effects: confusion, headache, blurred vision, chest pain, pulmonary edema, tachycardia, nausea, thirst, vomiting, renal failure, urinary retention, dehydration, hyperkalemia, hypernatremia, hypokalemia, hyponatremia, phlebitis at IV site
Nursing Implications:
-do not administer electrolyte-free mannitol with blood products
-confer with physician regarding placement of an indwelling Foley catheter
-administer by IV
Desired Outcome:
-urine output of at least 30 to 50 mL/hr or an increase in urine output
-reduction of ICP
-reduction in intraocular pressure
-excretion of certain toxic substances

Question 26

Phenytoin (Dilantin)

Answer 26

anti-seizure medication

• controls seizures
• can cause gingival hyperplasia

Question 27

Gingival Hyperplasia

Answer 27

cause from medication phenytoin (Dilantin)

• long-term side effect
• observe for swelling and bleeding of the child’s gums
• provides good dental hygiene

Question 28

Barbiturates

Answer 28

may be administered to reduce ICP
-cause the blood vessels in the brain to constrict, but the blood vessels in the rest of the body to dilate
>monitor status and blood pressure

Question 29

Pain and Agitation

Answer 29

treated aggressively if increased ICP is present
-nursing actions that may increase ICP: endotracheal suctioning, bathing, and positioning
>If the child’s ICP becomes dangerously high, the child is sedated, and if necessary, paralyzed; Narcotics such as morphine (Astramorphe) or fentanyl (Sublimaze) and benzodiazepines such as lorazepam (Ativan) are titrated to the desired effect

Question 30

Intracranial Pressure Monitoring

Answer 30

a pressure line is inserted to accurately monitor ICP
-intracranial bolts, intraventricular catheters, and intraparenchymal fiberoptic catheters
-indicated for a GSF score of less than 8, who exhibits signs of increasing ICP, who is post neurosurgical procedures, or who has a high probability of having increased ICP
>best outcome: maintain cerebral perfusion pressure between 50 and 70 mm Hg, for an ICP less than 20 mm, and monitor for occurrences such as herniation or bleeding

Question 31

Surgical Care: Craniotomy

Answer 31

incision through the cranium
-recommended when all other measures have been unsuccessful
-a complication of a craniotomy is herniation of the brain through the defect, leading to further edema and an increased ICP
>after procedure, assess the child for signs and symptoms of infection and increased ICP post-op

Question 32

Education/ Discharge

Answer 32

• incorporates knowledge of head injury and postprocedural care
• prevention measures, medications, referrals, and potential complications