NCM 118 (RLE)

(ER/ICU Case Scenario No. 1)

A Case Scenario on Increase Intracranial Pressure

2nd to Head Injury

1. Explain the anatomy and physiology of the brain.

The brain is composed of the cerebrum, cerebellum, and brainstem.

Cerebrum: is the largest part of the brain and is composed of right and left hemispheres. It
performs higher functions like interpreting touch, vision and hearing, as well as speech,
reasoning, emotions, learning, and fine control of movement.

Cerebellum: is located under the cerebrum. Its function is to coordinate muscle

movements, maintain posture, and balance.

Brainstem: acts as a relay center connecting the cerebrum and cerebellum to the spinal
cord. It performs many automatic functions such as breathing, heart rate, body
temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and
swallowing

The cerebral hemispheres have distinct fissures, which divide the brain into
lobes. Each hemisphere has 4 lobes: frontal, temporal, parietal, and occipital (Fig. 3). Each
lobe may be divided, once again, into areas that serve very specific functions. It’s
important to understand that each lobe of the brain does not function alone. There are very complex relationships between the
lobes of the brain and between the right and left hemispheres.

Frontal lobe

 Personality, behavior, emotions

 Judgment, planning, problem solving
 Speech: speaking and writing (Broca’s area)
 Body movement (motor strip)
 Intelligence, concentration, self-awareness

Parietal lobe
 Interprets language, words
 Sense of touch, pain, temperature (sensory strip)
 Interprets signals from vision, hearing, motor, sensory and memory
 Spatial and visual perception
Occipital lobe
 Interprets vision (color, light, movement)

Temporal lobe
 Understanding language (Wernicke’s area)
 Memory
 Hearing
 Sequencing and organization

The brain has hollow fluid-filled cavities called ventricles. Inside the ventricles is a ribbon-like structure called the choroid
plexus that makes clear colorless cerebrospinal fluid (CSF). CSF flows within and around the brain and spinal cord to help
cushion it from injury. This circulating fluid is constantly being absorbed and replenished.

CSF is produced inside the ventricles deep within the brain. CSF fluid
circulates inside the brain and spinal cord and then outside to the subarachnoid
space. Common sites of obstruction: 1) foramen of Monro, 2) aqueduct of Sylvius,
and 3) obex.

There are two ventricles deep within the cerebral hemispheres called the lateral
ventricles. They both connect with the third ventricle through a separate opening
called the foramen of Monro. The third ventricle connects with the fourth ventricle
through a long narrow tube called the aqueduct of Sylvius. From the fourth
ventricle, CSF flows into the subarachnoid space where it bathes and cushions the
brain. CSF is recycled (or absorbed) by special structures in the superior sagittal
sinus called arachnoid villi.
 A balance is maintained between the amount of CSF that is absorbed and the amount that is produced. A disruption or
blockage in the system can cause a buildup of CSF, which can cause enlargement of the ventricles (hydrocephalus) or cause a
collection of fluid in the spinal cord (syringomyelia). 1

2. Differentiate between Intracranial Pressure and Cerebral Perfusion Pressure.

Intracranial pressure (ICP) is defined as the pressure within the craniospinal compartment, a closed system that comprises a
fixed volume of neural tissue, blood, and cerebrospinal fluid (CSF). Cerebral perfusion pressure (CPP) is the net pressure
gradient that drives oxygen delivery to cerebral tissue. It is the difference between the mean arterial pressure (MAP) and the
intracranial pressure (ICP), measured in millimeters of mercury (mm Hg). 2

3. Discuss the pathophysiology of Increased ICP.

4. Describe the Monro-Kellie Theory’s relationship to Increased ICP.

The Monro-Kellie doctrine states that the skull is a rigid compartment and contains three components: brain, blood,
and cerebrospinal fluid. If an increase occurs in the volume of one component, the volume of one or more other
components must decrease, or ICP will be elevated. 3

Cushing conceptualized the Monro-Kellie doctrine stating that a change in blood, brain or CSF volume resulted in
reciprocal changes in one or both of the other two. When not possible, attempts to increase a volume further increase ICP. 4

5. What are the earliest and late signs of Increased ICP including the Cushing Triad?
Early Sign:
 Altered LOC: Irritability, Restless
 Decreased Mental Status
 Sleepiness
 Flat affect and drowsiness
Moderate Signs:
 Headache - Constant
 Sudden Vomiting “Emesis” Without Nausea
Critical LATE signs:
 Cushing triad
 Wide pulse pressure
o HIGH BP “Hypertension”
o Low HR “Bradycardia”
 Low RR “Decreased Respirations”
Late Deadly Signs:
 Lungs: irregular respirations, “Cheyne Stoked Respirations”
 Neck: Nuchal rigidity (stiff neck),” cannot flex chin toward chest”
 Brain Stem Affected:

1
Mayfield Brain & Spine. (n.d.). MAYFIELD. Retrieved September 16, 2022, from https://mayfieldclinic.com/pe-
anatbrain.htm#:%7E:text=The%20brain%20has%20three%20main,and%20fine%20control%20of%20movement.
2
Mount CA, M Das J. Cerebral Perfusion Pressure. [Updated 2022 Apr 5]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537271/
3
Pascual, J. M., & Prieto, R. (2012). Surgical Management of Severe Closed Head Injury in Adults. Schmidek and Sweet
Operative Neurosurgical Techniques (Sixth Edition), 1513-1538. https://doi.org/10.1016/B978-1-4160-6839-6.10133-9
4
Wilson M. H. (2016). Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of
intracranial pressure. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral
Blood Flow and Metabolism, 36(8), 1338–1350. https://doi.org/10.1177/0271678X16648711
 o Eyes:
 Pupils “fixed & dilated”
 Unequal
 8mm (normal 2-6mm)
 Doll’s eyes: this means Brain stem is intact!
 If the eyes stay fixed & dilated when the head is turned, it means Brainstem is affected.
o Foot:
 Babinski reflex (toes fan out when stimulated= BAD)
Means brain stem herniation which is not normal in adults.
 Seizures & Coma
 Abnormal posturing:
o Decorticate: arms flex toward core
o Decerebrate: arms flexed out to sides= far worse!

6. What is intracranial monitoring? and the methods used in monitoring Increased ICP.
Intracranial pressure (ICP) monitoring is a diagnostic test that helps your doctors determine if high or low cerebrospinal
fluid (CSF) pressure is causing your symptoms. The test measures the pressure in your head directly using a small
pressure-sensitive probe that is inserted through the skull. Spinal fluid pressure measured during a lumbar
puncture (spinal tap) provides an accurate value for intracranial pressure only at the time of the procedure. While this
will always be a valuable test to establish a diagnosis and monitor therapy, there are times when a more invasive
approach is necessary.5

7. Discuss the Glasgow Coma Scale and its relevance to the case presented.

Upon assessment, Mrs. Russin's initial GCS score is 14. LOC has deteriorated to GCS=9 (E=3, M=4, S=2). Pupils are
reactive to light and accommodation, pupil size is 2cm. After 2 hours in the ER, she was transferred to the Surgical ICU for
further management and care, with the latest GCS of 9 E=3, V=1 M=5. Neurovital signs were rechecked GCS=3 E=1, V=1,
M=1 5mm pupil size, sluggish non-reactive to light and accommodation, suctioning of endotracheal and oral secretions done
PRN. On the 2nd-day patient's condition worsened, GCS=3 no urine output.

The most used scoring system for determining a person's level of consciousness after a traumatic brain injury is the
Glasgow Coma Scale (GCS). In essence, it is employed to determine the severity of an acute brain damage. The exam is
straightforward, trustworthy, and has good correlations with recovery from serious brain injury. The GCS is a trustworthy
and impartial technique to document a person's initial and continued level of consciousness after a brain injury. 6 Based on
the case GCS is relevant to determine the LOC of Mrs. Russin, and for her last GCS scoring of GCS 3 it is an indicative of
Moderate Brain Injury. A GCS score of 3 is the lowest possible score and is associated with an extremely high mortality
rate, and with scores of 3 to 8 are usually considered to be in a coma.

8. Discuss the medical and surgical management of a client experiencing Increased ICP.

The ICP monitor may be implanted in surgical patients at the conclusion of the operation. ICP monitoring is kept up for
3 to 5 days, or however long it takes to treat intracranial hypertension. 30% of patients with intracranial hypertension may
experience a subsequent rise in ICP 3 to 10 days after trauma as a result of delayed intracerebral hematoma development,
cerebral vasospasm, or systemic variables such hypoxia and hypotension. Sedation, CSF draining, and osmotherapy with
either mannitol or hypertonic saline should all be used in the medical management of elevated ICP. Barbiturate coma,
hypothermia, or decompressive craniectomy should be taken into consideration for intracranial hypertension that is resistant
to initial medical therapy.7

9. Identify the drugs used by the patient as well as other drugs possibly used for clients with Increased ICP.

Medications given to the patient are the following:

 Tramadol a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and
nervous system respond to pain.
 Mannitol a diuretic. It helps make more urine and to lose salt and excess water from the body. It treats swelling
from heart, kidney, or liver disease. It also treats swelling around the brain or in the eyes.
 Dexamethasone belongs to a class of drugs known as corticosteroids. It decreases the immune system's response
to various diseases to reduce symptoms such as swelling and allergic-type reactions.
 Paracetamol or Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics
(fever reducers).
 Furosemide belongs to a group of medicines called loop diuretics (also known as water pills).
 Tetanus Toxoid also known as tetanus toxoid (TT), is a toxoid vaccine used to prevent tetanus.

5
Ciattei, J. (2018, February 8). ICP Monitoring: Direct | Department of Neurology and Neurosurgery. Retrieved October 1,
2022, from https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/cerebral-fluid/
procedures/icp-monitoring-direct.html#:%7E:text=Intracranial%20pressure%20(ICP)%20monitoring%20is,is
%20inserted%20through%20the%20skull.

6
What Is the Glasgow Coma Scale? (2022, June 8). BrainLine. Retrieved October 3, 2022, from
https://www.brainline.org/article/what-glasgow-coma-scale
7
Rangel-Castilla, L., Gopinath, S., & Robertson, C. S. (2008). Management of intracranial hypertension. Neurologic
clinics, 26(2), 521–x. https://doi.org/10.1016/j.ncl.2008.02.003
  Cefuroxime is used to treat bacterial infections in many different parts of the body. It belongs to the class of
medicines known as cephalosporin antibiotics.
 NaHCO3, Sodium bicarbonate, is an antacid used to relieve heartburn and acid indigestion.
 Omeprazole is in a class of medications called proton-pump inhibitors. It works by decreasing the amount of
acid made in the stomach
 Midazolam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow
relaxation and sleep.

Other medications possibly used for clients with Increased ICP:

 Osmotic diuretics, (e.g., urea, mannitol, glycerol) and loop diuretics (e.g., furosemide, ethacrynic acid) are first-
line pharmacologic agents used to lower elevated ICP. Corticosteroids may be beneficial in some patients. 8

10. Make at least 2 NCP for this patient and formulate an appropriate nursing diagnosis as the basis for planning and
management.

11. How would you perform Post Mortem Care with this type of patient?

Care for patients doesn't cease with death. If the patient passes away in a hospital or medical facility, the nurse is
responsible for informing the attending physician, other healthcare professionals involved in the patient's care, and the
necessary staff (such as the house supervisor). The nurse is in charge of numerous post-mortem care duties after the
attending provider has declared a patient dead, including final paperwork, care and final disposition of the body, and
offering support to the family. Since these duties can be emotionally taxing, the nurse must also set aside time for self-care.

Steps in providing nursing care for the dead.

1. The patient has pronounced dead by the doctor, place the body in dorsal position with only a small pillow
under the head.
2. Straighten the body.
3. See that dentures are placed in the mouth if patient has any
4. Remove all appliances; catheters, drainage tubings, Venoclysis sets, etc.
5. Close the eyes and mouth when open.
6. Eyes—bring upper lid down to the lower and apply gentle pressure over it for a while.
7. Mouth—bring the jaws together by placing a rolled towel under the chin.
8. Remove extra bed linen and camisa. Leave one sheet to cover the body.
9. Bathe the body using the Lysol solution to rinse.
10. Change surgical dressings p.r.n. Pack anus with cotton. Vagina (if female). If there is any discharge from the
nose and mouth, pack them too. Use forceps.
11. Place the diaper.
12. Full hands over the chest. Pad wrists with cotton and the tie the 2 wrists together with bandage. Attach one tag
to the wrist.
13. Pad the ankles and tie them together.
14. Put on the shroud. Wrap body with a sheet well. Attach the other tag at the center
15. Cover the prepared body with a sheet and notify the head nurse or call for the messenger to take the body to the
morgue.9

8
Woster, P. S., & LeBlanc, K. L. (1990). Management of elevated intracranial pressure. Clinical pharmacy, 9(10), 762–
772.
9
Vera, M. B. (2016, January 31). Nursing Care of the Dead. Nurseslabs. Retrieved October 3, 2022, from
https://nurseslabs.com/nursing-care-of-the-dead/