MODULE 2

MANAGEMENT OF CLIENT WITH INCREASE INTRACRANIAL PRESSURE

Intracranial Pressure – is the pressure normally exerted by CSF that circulates around the
brain & Spinal Column within the cerebral ventricles.

Increased Intracranial Pressure ( ICP)

⚫ Definition : Is the general name for the disorders in which the cerebro-spinal fluid (CSF)
pressure within the skull is too high.
⚫ Old names for IH include Benign Intracranial Hypertension and Pseudotumor Cerebri.
⚫ Normal range of ICP : 10-20 mm Hg

Common Causes : Trauma, Hemorrhage, growth of tumors, hydrocephalus,

Edema or Inflammation

TWO CATEGORIES OF Intracranial Pressure

⚫ Primary or Idiopathic Intracranial Hypertension (IIH)

⚫ is IH without an identifiable causative agent. In other words, IIH occurs

spontaneously, without a known cause.

⚫ Secondary Intracranial Hypertension

⚫ is IH with an identifiable, causative agent, such as another underlying disease, an

intracranial blood clot (dural sinus thrombosis), or certain drugs.

⚫ Cerebral Response to Increased ICP

⚫ Monro-Kellie Hypothesis:

The average intracranial volume in adult is approximately 1,700ml

This composed of the : Brain : 1,400ml

CSF : 150ml
Blood : 150ml
Total : 1,700ml
 ⚫ Due to the skull’s limited expansion, an increase in any of the components of the brain
causes a change in the volume of others by displacing or shifting CSF, increasing
absorption of CSF or decreasing blood volume.

( It state that the skull, a rigid compartment is filled to capacity with essentially
noncompressible content interstitial fluid – 80% INTRVASCULAR Blood & 20% CSF. If
the volume of any component increases, another component – MUST DECREASE
reciprocally for the overall volume and dynamic equilibrium to remain constant, otherwise
ICP will rise.
⚫ Autoregulation: Brain has the ability to change the diameter of its blood vessels
automatically to maintain constant cerebral blood flow

Cushing’s Response/Reflex:
⚫ The arterial pressure increase in an attempt
to restore blood flow

Early signs of Increased ICP

• Loss of Consciousness – most sensitive &

Earliest indication of increasing ICP
⚫ Disorientation
⚫ restlessness
⚫ increased respiratory effort
⚫ Anisocoria (unequal pupil size)
⚫ Weakness on one extremity
⚫ Constant headache increasing in intensity
aggravated by movement or straining
• Projectile Vomiting due to the compression of the
brain
⚫ Hemiplegia
⚫ decorticate
⚫ decerebrate posture develops
⚫ Bilateral flaccidity occurs before brain death
⚫ Loss of brain stem reflexes: pupillary reflexes, gag reflex (ominous sign)

• Late signed of Increased ICP : Inc. Systolic Pressure

: Widened Pulse Rate
: Slowed Heart Rate

General Signs and Symptoms

⚫ Changes in level of consciousness

 ⚫ Cushing’s triad: bradycardia
widening pulse pressure
bradypnea

ICP monitoring:

ICP monitoring is most often used in head trauma in the following situations:
1) GCS less than 8
2) Drowsy with CT findings (operative or non operative)
3) Post op hematoma evacuation

4) High risk patients

(a) Above 40 yrs.
(b) Low BP
(c) Those who requires ventilation.

Complications

⚫ Brain stem herniation

⚫ Irreversible brain anorexia and brain death
⚫ Diabetes insipidus & Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Medical and/or Surgical Management:

• Monitor ICP either via ventriculostomy, subarachnoid bolt, epidural or subdural catheter
and fiberoptic transducer-tipped catheter
• Osmotic diuretics (mannitol) and corticosteroids
• Inotropics (e.g. dobutamine hydrochloride)
• Reduce CSF and blood volume by draining CSF via vetriculostomy drain.

Nursing Management

Assess the level of consciousness using Glasgow Coma Scale

Monitor for Cheyne-Stoke breathing and ataxic breathing (irregular
breathing with random sequence of deep and shallow breaths)
Monitor for hemiplegia, decorticate or decerebrate posturing.
Monitor for loss of brain stem reflexes
H – Head elevated to 30degrees to promote venous drainage & respiratory
function. This would be contraindicated if the client has SPINAL
CORD INJURY.
E – Evaluate neurologic status (ICP). The 1st sign of a change in the intra
cranial pressure in an alteration in the LOC. Pupils also should react
to light.
A – AIRWAY. Evaluate current respiratory pattern. May require intubation
and control in the volume ventilator.
D – DRAINAGE – drainage from the ears may be Cerebral Spinal Fluid.
A CSF leak would test for positive for glucose.

Nsg. Care : Apply a sterile dressing over ear and evaluate for signs
of meningitis
S – Seizure Precautions.
Nsg. Care :
a. NO sedatives or narcotics.
b. Restrict fluids.
c. Control temp, & avoid coughing, sneezing, vomiting
d. Over suctioning, rectal examination

1. Osmotic Diuretics ( Corticosteroids)

2. Chlorpromazine ( Thorazine) to control shivering
3. Barbiturates decrease cellular metabolic demand
4. Phenytoin NA ( anticonvulsant)Administer after meal
to prevent GI upset

Common Drugs Used for client with altered neurologic functions

a. Phenobarbitals
b. Hydantoins
c. Benzodiazepines
d. Carbamazepine
e. Phenytoins
f. Valproic Acid
g. Furosemide
 h. Mannitol
i. SumaTriptan
j. DihydroErgotamine
k. Acetaminophen
l. Lactulose
m. Thorazine
n. Demerol
o. Propofol
p. Dexamethasone
q. Dantrolene (Dantrium)
r. Penicillin
s. Ceftrioxone Na
t. Prostigmine
u. Corticosteroid(prednisone)
v. Riluzole
w. Neurontin
x. Quinine
y. Levodopa
z. Symmetrel
aa. Dopamine HCl
bb. Dobutamine HCl
cc. Citicholine
dd. Nicardipine
ee. Vit. B complex
ff. Nimodipine
gg. aspirin

Nursing Management for Client Using Lactulose

A. Administer stool softener ( Lactulose- cephulac) and suppositories as ordered to prevent
constipation and fecal impaction
1. Report DIARRHEA
2. Monitor Serum Ammonia level
3. ( decrease serum ammonia level)
4. Administer with juice to disguise the taste
B.corticosteroids to decrease cerebral edema
C. Anticonvulsant drug to prevent seizures
D. Anticoagulants for stroke in evolution or embolic stroke.

Nursing Management for AntiCoagulant (Warfarin NaCoumadin)

Prevent thrombus formation
1.Avoid Green Leafy vegetables as the Vit. K content of these vegetables interfere with the
absorption of the drug.
2.Avoid contact sports
3.Assess for sign of bleeding
4.Keep the vit. K at the bedside (ANTIDOTE)

1.Osmotic Diuretics ( Cerebral edema reduction)

2. Chlorpromazine ( Thorazine) to control shivering

3. Barbiturates decrease cellular metabolic demand

4. Phenytoin NA( anticonvulsant)

Administer after meal to prevent GI upset

5. Antipyretic for fever control fever

Nursing Management for Client taking Phenytoin

1.Best taken with food to enhance absorption

2. Massage the gums, it causes gingival hypertrophy

3. Inform client that the urine will turn to pink, red or reddish brown.

4. Do not discontinue abruptly & monitor for s/sx of bone marrow depression

5. Use SALINE flush before & after IV administration

6. Report for skin rash.

Drfrida_27’2021