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NURS 3512 - Class 7-12 > Week 10 - Increased ICP > Flashcards

Week 10 - Increased ICP Flashcards

1
Q

The brain is like a closed boxed with what 3 essential components

A
  • tissue
  • blood
  • CSF
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2
Q

what intracranial pressure (ICP)

A
  • the pressure exerted bc of the combined total volume of the 3 components in the skull
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3
Q

what is the Monro-Kellie doctrine

A
  • describes how a state of equilibrium is maintained by the volume relationship of the 3 components within the skull
  • if the volume of any of the 3 components increases, the volume from another component is displaced so ICP isnt changed
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4
Q

what causes increased ICP (IICP)

A
  • if the volume of any of the 3 components in the skull increases without a corresponding decrease in another component
    ex. inflammation, infection, bleeding
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5
Q

what factors influence ICP (6)

A

changes in:

  • BP
  • cardiac function
  • intra-abdominal and intrathoracic pressure (coughing, sneezing)
  • body position
  • temp
  • blood gasses
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6
Q

what is normal ICP?

A

<15

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7
Q

what is considered IICP

A

> 20 mmHg

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8
Q

why is IICP clinically significant

A
  • IICP = decreased CPP = risk of brain ischemia and infarction = poor prognosis and brain damage
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9
Q

what is CPP?

A

cerebral perfusion pressure

- the pressure needed to ensure adequate brain tissue perfusion

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10
Q

how is CPP calculated

A

= MAP - ICP

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11
Q

what is considered normal CPP? a CPP less than ___ = cerebral ischemia?

A
  • normal: 70-100 (goal = keep above 70)

- less than 50

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12
Q

how does IICP = decreased CPP

A
  • during IICP the brain becomes so tight and edematous that the vessels are squeezed = inadequate cererbral perfusion
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13
Q

describe the relationship between BP and CPP; what indication does this have in nursing care

A
  • a drop in BP = drop in CPP

= need to monitor BP in addition to ICP and CPP
= meds may be used to increase BP based on SBP goal ordered

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14
Q

sustained increases in ICP =?

A
  • causes brainstem compression and herniation of the brain from one compartment to another
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15
Q

compression of the brainstem d/t herniation impacts? (4)

A
  • respiratory center
  • cardiac function
  • sucking reflex
  • motor function
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16
Q

what is primary injury

A
  • happen at the time of injury

ex. hitting head on rock

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17
Q

what is secondary injury

A
  • happens several hours to days after injury

ex. primary injury leads to IICP

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18
Q

how long is treatment for IICP typically required

A
  • several days to 2 weeks
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19
Q

what may be done for patients w IICP? why?

A
  • may “induce coma” thru use of paralytics, benzos, and narcotics
  • this allows the brain to rest = decreased ICP
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20
Q

how does the brain tissue component try to compensate for IICP (2)

A
  • distension of dura

- compression of tissue

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21
Q

how does the blood component on the skull try to compensate for IICP

A
  • vasoconstriction of cerebral vessels
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22
Q

how does CSF try to compensate for IICP (2)

A
  • production slows down

- displaced to spinal column

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23
Q

what are some examples of how the tissue component of ICP can be increased (4)

A
  • cerebral neoplasm
  • contusion
  • abcess
  • cerebral edema
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24
Q

what are some examples of things that cause cerebral edema (3)

A
  • increased CO2
  • decreased PaO2 (<50)
  • elevated H+ conc. (lactic acid released from low PaO2 = anaerobic metabolism)
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25
Q

due to some of the factors that can cause cerebral edema, what is imp to monitor (2)

A
  • ABGs –> CO2 and O2 lvls

- resp system –> RR, sats, breathing pattern, snoring ?? (=less O2)

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26
Q

what are some signs of IICP (6)

A
  • change in LOC
  • change in VS –> Cushing’s triad & changes in body temp
  • ocular changes
  • decreased motor function
  • HA
  • vomitting (w/o nausea)
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27
Q

what is the most sensitive and earliest indicator of IICP

A
  • change in LOC
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28
Q

what is cushing’s triad (4)

A
  • increasing systolic P
  • widening pulse P
  • bradycardia w a full and bounding pulse
  • irreg resp. pattern
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29
Q

what ocular changes may be seen w IICP (5)

A
  • ipsilateral dilation
  • bilat. dilated, fixed pupils (ominous sign)
  • sluggish or no response to light
  • inability to move the eye upward
  • ptosis of the eyelid
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30
Q

a change in pupil size of ____ means you should notify the physician

A
  • change in 2-3 mm
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31
Q

what changes in motor function may occur w IICP (3)

A
  • contralateral hemiparesis or hemiplegia
  • decorticate posturing
  • decerebrate posturing
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32
Q

what does decorticate posturing mean?

A
  • d/t disruption of the voluntary motor tracts

- damage to one or both corticospinal tracts

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33
Q

what does decorticate posturing look like?

A
  • internal rotation and adduction of the arms w flexion of the elbows, wrists, and fingers
  • extension of legs and internally rotation
  • plantar extension of feet
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34
Q

what does decerebrate posturing mean

A
  • more serious damage

- disruption of motor fibres in the midbrain and the upper brainstem

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35
Q

what decerebrate posturing look like

A
  • arms stiffly extended, adducted, and hyperpronated

- hyperextension of legs w plantar flexion of the feet

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36
Q

what are early signs (comp mechanisms intact) of IICP (8)

A
  • altered LOC –> confusion, restless
  • unilateral pupil change in size, equality, reactivity
  • unilat hemiparesis
  • vomitting
  • HA
  • seizures
  • papilledema
  • focal findings (speech difficulty, visual disturbances)
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37
Q

what are late signs (compensatory mechanisms failing) of IICP (5)

A
  • decreased LOC –> stupor
  • unilat or bilat pupillary changes
  • Cushing’s triad
  • abnormal motor response –> decorticate or decerebrate posturing
  • hyperthermia
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38
Q

what are terminal signs (decompensation) of IICP (6)

A
  • bilat fixed & dilated pupils
  • resp arrest
  • absence of motor response (flaccid)
  • HTN w widened pulse P
  • bradycardia
  • hyperthermia
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39
Q

what are 2 complications of IICP

A
  • inadequate cerebral perfusion

- cerebral herniation

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40
Q

what diagnostic studies are used to differentiate the many conditions that can cause IICP (5)

A
  • MRI
  • CT brain/head (quicker & more accurate than MRI)
  • MRA
  • CTA
  • xray skull or facial bone fractures
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41
Q

when is a CT of the brain/head done r/t neuro problems (??)

A
  • done initially
  • then repeated in 24-48 hrs
  • and again if further pt decline (ex. decreased LOC, increased ICP)
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42
Q

what other diagnostic studies are used for IICP/neuro (6)

A
  • cerebral angiography (clot? aneurysm?)
  • EEG (seizures?)
  • ICP measurement
  • brain tissue oxygenation measurement via LICOX
  • transcranial Doppler (vasopasm? velocity of blood flow)
  • LP (obtain CSF determine if infection or blood)
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43
Q

when is ICP typically monitored (2)

A
  • if GCS <8

- abnormal CT or MRI (edema, contusion, hematoma, etc.)

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44
Q

why is ICP monitored

A
  • to guide clinical care when pt has or is at risk of IICP
45
Q

what is an example of a device used to monitor ICP

A
  • external ventricular drain (EVD) (or just ICP monintor)
46
Q

what does an EVD do (3)

A
  • determines ICP
  • determines CPP
  • and can remove/drain CSF to decreased ICP
47
Q

what is an EVD

A
  • involves insertion of a catheter into ventricle (ventriculostomy) connected to a transducer (which translates the ICP and CPP)
48
Q

what is included in care for pt on EVD (3)

A
  • bed rest
  • potential prophylactic antibiotics d/t risk of infection
  • constant positioning of the external transducer relative to the position of the pt’s head to maintain consistent measurements
49
Q

what are the goals of collab care for IICP

A
  • identify and treat the underlying cause of increased ICP

- support brain function

50
Q

what is the first step in mngmt of increased ICP

A
  • ensuring adequate oxygenation to support brain frunction
51
Q

what is involved in care r/t ensuring adequate oxygenation for brai function (3)

A
  • ABGs to guide oxugen therapy
  • possible endotracheal tube or tracheostomy
  • possible mechanical ventilator
52
Q

what is the goal PaO2 for IICP

A
  • > 100 mmHg
53
Q

what med is frequently used to decrease ICP

A
  • Mannitol
54
Q

what is Mannitol

A
  • an osmotic diuretic given IV that decreases ICP = fluid moves from tissue into vessels
55
Q

describe how mannitol decreases ICP

A
  1. plasma expansion –> decreases hct and blood viscosity = increased cerebral blood flow and O2 delivery
  2. osmotic effect –> moves fluid from tissues into vessels
56
Q

what type of IV fluid may be given as part of treatment for IICP

A
  • hypertonic saline
57
Q

describe the use of corticosteroids for IICP

A
  • used to control edema surrounding tumours and abcesses

- not for diffuse cerebral edema

58
Q

what are some complications associated w corticosteroids (4)

A
  • hyperglycemia
  • increased r/o infections
  • GI bleeding
  • hyponatremia
59
Q

pts receiving corticosteroids should also be on ??? why (3)

A
  • antacids, H2RB, PPI to prevent GI ulcers and bleeding
60
Q

describe the use of barbituates for IICP (3)

A
  • used to reduce cerebral metabolic = decreased ICP
  • dampens the effects of environmental stimuli
  • reduces cerebral edema
61
Q

describe the use of antiseizure meds for IICP

A

ex. dilantin (phenytoin)
- used to prevent seizures bc they cause = increased ICP
- additionally, in pts w head injury they are at a risk of seizures d/t the irritation and stress on the brain

62
Q

describe nutritional therapy for pts w IICP (6)

A
  • pt in a hypermetabolic and hypercatabolic state = increased need for glucose to provide fuel for brain & burn lots of calories = r/o muscle wasting
  • if pt cannot maintain adequate oral intake, may require other means of meeting nutritional requirements (tube feed, TPN, etc.)
  • will require feedings for optimal nutrition
  • dietician involved
  • early feedings (within 5 days of injury) have been shown to improve outcomes
  • keep stomach working (empty stomach = r/o ulcers)
63
Q

what assessments are done w pts w IICP (5)

A
  • glascow coma scale
  • neurological assessment
  • monitor ICP and CPP
  • monitor ABGs
  • monitor BP for SBP goal
64
Q

what 3 areas of focus are include in the GCS

A
  • eye opening
  • best verbal response
  • best motor response
65
Q

what is included in neuro assessment for pts w IICP (5)

A
  • pupils (PERRLA)
  • motor strength bilat
  • can pt follow commands?
  • palmar drift
  • VS
66
Q

what does cushing’s triad indicate

A
  • medical emergency

= severe IICP and impending cerebral herniation

67
Q

how often is neuro and GCS assessment done in pts with IICP in the ICU? step down unit? neuro unit?

A
  • ICU = qh
  • step down = q1-4h
  • neuro unit = q4-8 hr
68
Q

what are some things that worsen ICP (10)

A
  • seizure (EEG)
  • pain
  • irritating issue /noxious stimuli
  • fear & anxiety
  • fever
  • coughing
  • straining
  • re-bleed
  • increase in cerebral edema
  • increased BP
69
Q

what meds may be used to induce hypertension to meet goal SBP

A
  • IV vasopressors
70
Q

describe the environment for a pt w IICP (4)

A
  • quiet
  • dark
  • calm, quite voice
  • towel over eyes pre surgery
71
Q

what guides our nursing care

A
  • ICP and CPP

ex. may premedicate for interventions like turning, drsg changes –> also let brain “rest” after interventions

72
Q

describe pt positioning w IICP (7)

A
  • HOB 30 (prevent hypoxia, enhances resp exchange, decreases cerebral edema)
  • neutral neck (to enhance blood flow, prevent venous congestion)
  • turn q2-3h with slow gentle movements (rapid changes in position = IICP, avoid pain which = IICP) –> consider ICP before & requires 2-4 people
  • caution when turning due to drain in brain, IV, foley etc.
  • keep body midline (prevent abdominal and intrathoracic pressure)
  • decrease stimuli
  • avoid hip flexion (= increased intrabdominal pressure)
73
Q

describe pt temperature r/t IICP

A
  • keep temp normal or low
  • may require cooling blanket

(increased temp = IICP)

74
Q

describe pt temperature r/t IICP

A
  • keep temp normal or low
  • may require cooling blanket

(increased temp = IICP)

75
Q

describe oxygenation r/t IICP (3)

A
  • keep oxygenation high & prevent hypoxemia
  • may require intubation & ventilate
  • prevent CO2 from rising
76
Q

describe CSF drainage r/t IICP

A
  • drain CSF per Dr orders (turn valve)
77
Q

what supportive care is included for IICP (3)

A
  • tube feeds
  • prevention of gastric stress ulcers
  • prevent problems associated w immobility
78
Q

what is an important consideration if a pt is wearing an aspen collar w IICP

A
  • make sure it is not too tight –> ~2 fingers fit (otherwise would impact perfusion and drainage)
  • perform collar care q24 hr and PRN
79
Q

describe nursing care r/t resp. function (7)

A
  • ensure maintenance of patent airway
  • position patient so lying on the side (as LOC decreases r/o airway obstruction d/t tongue dropping)
  • note any snoring (may indicate obstruction)
  • remove accumulated secretions via suction (imp bc if unconscious pt cannot cough)
  • possible intubation and ventilation (if cannot maintain patent airway d/t decreased LOC)
  • position HOB 30
  • monitor ABGS –> appropriate ventilatory support ordered on this basis
80
Q

what is an important nursing consideration r/t suctioning (3)

A
  • should be less than 10 sec in duration (suctioning can cause changes in PaO2= IICP)
  • limit to 2 passes per suction procedure (to avoid accumulative changes in ICP)
  • provide O2 before and after
81
Q

why is it important to prevent abdominal distension in pts w IICP (5)

A
  • can interfere w resp function
  • increased intra-abdominal pressure can = IICP by impeding cerebral venous drainage
  • prevent vomiting
  • prevent aspiration
82
Q

what are some ways to prevent abdominal distension (2)

A
  • insertion of NG tube to aspirate stomach contents (if no facial or skull fracture)
  • insertion of an oral gastric tube if presence of facial or skull fracture
83
Q

why might sedatives, paralytics, and analgesics be given to pts w IICP? what is a challenge w these?

A
  • to prevent pain, fear, anxiety, etc. from = IICP
  • challenge: these meds may alter the neuro state = mask true neuro changes = may be necessary to suspend meds to appropriately assess neuro status
84
Q

why is it important to monitor fluid and electrolyte balance for IICP

A
  • fluid and electrolyte disturbances may = IICP
  • too much fluid = IICP
  • additionally, hypovolemia = decreased CPP
85
Q

what is included in nursing care r/t fluid and electrolyte balance

A
  • monitor fluid accuratelly
  • monitor I&O
  • monitor weight
  • monitor electrolytes (bc diruetics and IV fluid may effect)
  • monitor urine output
86
Q

in particular, what electrolytes should be monitored for IICP (4)

A
  • Na (don’t want too high d/t mannitol, r/o DI and SIADH, r/o cerebral salt wasting)
  • K
  • osmolality ( dont want too high d/t mannitol, r/o DI and SIADH)
  • glucose
87
Q

why is it imp to monitor urine output w IICP

A
  • IICP = risk of developing DI or SIADH
88
Q

what are signs of DI

A
  • increased urine output

- dehydration

89
Q

what is treatment for DI (3)

A
  • IV fluids
  • vasopressin
  • DDAVP
90
Q

what are signs of SIADH (4)

A
  • dilutional hyponatremia = increased cerebral edema
  • change in LOC
  • seizures
  • coma
91
Q

what is cerebral salt wasting

A
  • low Na due to excesssive renal sodium excretion (thru urine output)
  • associated w cerebral injury
92
Q

what is treatment for cerebral salt wasting

A
  • salt tabs
93
Q

what does supportive care for IICP focus on

A
  • reduce metabolic demands as much as possible to prevent further IICP
94
Q

what is included in supportive care for IICP (9)

A
  • control fever –> temp q4h, tylenol, determine cause
  • monitor for seizures (seizure = IICP) –> prophylactic dilantin
  • manage pain (can’t tell us, we assume they have pain) –> narcotic
  • decrease stimuli –> dark, quiet enviro, keep pt comfy w pillow
  • use ICP to guide care –> turning, mouth care, etc.
  • sedatives to let brain relax (turn off/down to see how ICP reacts)
  • monitor family visits (loud noise can = IICP)
  • allow ICP to return to baseline between necessary nursing activities
  • do not cluster nursing care
95
Q

describe nursing care r/t protection from injury (5)

A
  • least restraint approach (d/t confusion, seizures don’t want them to touch their ICP monitor, etc., r/o self injury) —> reassess need for restraints daily
  • assess restrained extremities q2h
  • if restraints = more agitation , may need light sedation
  • pad side rails
  • calm, reassuring approach
96
Q

describe nursing care r/t psychological care (4)

A
  • anxiety over diagnosis
  • competent assured manner
  • short, simple explanations (ex. why they are sedated)
  • allow family participation in care when possible
  • explain what you do when family isnt there
97
Q

what are some things to avoid r/t IICP (7)

A
  • overstimulation (noise, lots of activity in short time, bright lights)
  • avoid flexion of hips
  • avoid head turned
  • do not keep bed flat
  • not treating fever
  • not treating pain
  • an increase in cerebral metabolism (shivering, seziures, etc.)
98
Q

list some meds that are used for IICP (12)

A
  • sedatives (decrease cerebral metab)
  • analgesics & narcotics (pain & sedation)
  • high-dose barbs and/or paralytics in ICU (decrease cerebral metab.)
  • antiseizures
  • antipyretics (q6h)
  • mannitol (decrease cerebral edema and blood visocity)
  • nimodipine (for vasospasm)
  • corticosteroids (if tumour or abscess, not for diffuse cerebral)
  • hypertonic saline (decrease swelling, draw water out of brain tissue)
  • stool softener
  • H2RB, PPI, antacids (prevent gastric ulcer/bleeding)
  • antibiotics
99
Q

what are some nursing considerations r/t hypertonic saline (3)

A
  • monitor Na
  • monitor BP and for fluid overload
  • infuse at slow rate
100
Q

what is an example of a steroid used for brain tumour and IICP

A

decadron

101
Q

what are signs of IICP (10)

A
  • IICP increase on monitor
  • CPP decrease on monitor
  • pt less awake or not as responsive (decreased LOC)
  • decrease in motor functioning
  • posturing
  • pupil dilation, sluggish reaction
  • HA
  • vomitting w/o nausea
  • change in body temp (indicates pressure on pons)
  • changes in VS (cushing’s)
102
Q

what is a craniotomy

A
  • bone flap removal to make room for adaption to decrease ICP
  • done under general anasthetic
103
Q

what are nursing considerations for a pt following a craniotomy (3)

A
  • do not put P on the effected side
  • do not turn patient onto side where bone is missing
  • helmet for protection
104
Q

what are complications of uncontrolled IICP (5)

A
  • low CPP (Pressure squeezes vessels and arteries)
  • cerebral herniation (often down towards brainstem)
  • cushing’s traid (terminal)
  • herniation downward thru foramen magnum and compresses medulla = often fatal
  • brain death
105
Q

describe the criteria for brain death

A
  • cerebral cortex has no function or is irreversibly damaged
  • coma
  • absence of brain stem reflexes
  • pt is apneic
  • pt organ donor
  • very different from being in a persistent vegetative state*
106
Q

what tests may be done to determine if a pt is “brain dead” (3)

A
  • apneic test
  • dolls eye test
  • cold caloric test
107
Q

a nursing diagnosis r/t IICP is risk for ineffective cerebral tissue perfusion. what are some nusing interventions for this (6)

A
  • consult w physician for hemodynamic parameters (ex. BP)
  • induce hypertension w vasoconstrictive meds (ex. vasopresson)
  • neck neutral position, HOB 30
  • monitor determinants of tissue O2 delivery (PaO2, SaO2, hgb, cardiac output)
  • monitor neuro status
  • monitor I&O to assess effects of diuretic therapy
108
Q

a nursing diagnosis r.t IICP is risk for disuse syndrome. what are some nursing interventions for this (8)

A
  • position pt to maximize ventilation potential
  • remove secretions by suctioning
  • chest physical therapy
  • turn q2h and with care
  • prevent pressure injury risk
  • perform passive or assisted ROM
  • complete nutriitonal assessment
  • determine need for enteral tube feedings

NURS 3512 - Class 7-12 (49 decks)

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