Overview of Increased Intracranial Pressure

This is Sarah with RegisteredNurseAriene.com and in this video I'm going to be going over increased intracranial pressure. And this video is part of an NCLEX review series over the neurosystem. And as always, after you watch this video, don't forget to access the free quiz that will test you on this condition. So let's get started. First, let's start out talking about what is increased intracranial pressure. It is where the pressure that normally resides within the skull has dramatically increased and this is a medical emergency. The patient needs treatment fast because as that pressure builds it can actually lead to brain death. Now how is intracranial pressure created within the skull? It's created by the cerebral spinal fluid, the CSF, the brain's tissue, and blood. And we can actually measure intracranial pressure whenever we are monitoring a patient who has this condition. They can place special devices either in the lateral ventricle or sometimes in the subarachnoid space and it can tell us what those pressure readings are running. And a little bit later in the lecture, we will go into detail about those monitoring devices. So what is a normal intracranial pressure? And I would commit this number to your memory. So a normal ICP is anywhere between 5 to 15 millimeters of mercury. Now, if the pressure increases greater than 20 millimeters of mercury, the patient needs immediate treatment. So remember the number, 5 to 15. 15. That's where we want our patient. Now let's take a closer look at the human skull. As you can tell it is very hard and it is limited on how much it can really expand when something inside the skull experiences a change that will lead to increased pressure within it. Now inside the skull are three structures that I want you to remember that can alter intracranial pressure because it's going to help us understand Monroe-Kelly hypothesis. along with the treatment and everything for this condition. So those structures include the brain, the cerebral spinal fluid, the CSF, and the blood within the brain. And in the blue, you can see this is where the cerebral spinal fluid is. It flows around the brain and down through the spinal cord. Now, intracranial pressure is interesting because it fluctuates and it can increase depending on certain... factors that influences it. So I want you to remember these factors because whenever we're talking about nursing interventions and treatments we're going to go back to these factors and see how we can intervene to help correct this increased intracranial pressure. So some factors that can alter increased intracranial pressure is body temperature. For instance, hyperthermia. If a patient's running a temperature this can increase intracranial pressure. Also, oxygenation status especially the carbon dioxide and O2 levels. If our patient is hypoxic, this can increase intracranial pressure, or if their CO2 level is too high, this can cause vasodilation, which increases the cerebral blood flow to the brain and this increases intracranial pressure. Also, body position can. So as a nurse, we want to make sure we are aligning our patient's body correctly so we don't increase intracranial pressure like keeping their neck midline we don't want it flex and keeping them at a certain angle 30 to 35 degrees also arterial and venous pressure can affect it and anything that increases intra-abdominal and thoracic pressure like vomiting and bearing down or even flexing their hip can increase that pressure in the abdomen which in turn increases intercranial pressure pressure. Now let's talk about the theory on how the body tries to compensate for whenever a patient is experiencing increased intracranial pressure. Well to do that we have to talk about Monroe-Kelly hypothesis. You really can't talk about intracranial pressure unless you discuss this because it gives us our pathophysiology on how really this condition is happening. So what it says and what it deals with is how the intracranial pressure is affected by those three important structures that we just went over. the cerebral spinal fluid, the brain's blood and tissue. And these three structures work together to maintain the cerebral perfusion pressure, the CPP. And I want you to remember that term because it's really important whenever we're talking about increased intracranial pressure, and we're going to discuss it in depth here in a moment. So what does this hypothesis say? In a nutshell, what it's talking about, it's saying that if there is an increase in volume of one of those three structures that we just talked about, the other structures that aren't being affected are going to have to decrease. their volume to help alleviate that pressure that is building. And how does it do this? It can do this by taking that CSF, the cerebral spinal fluid, and moving it somewhere else in the brain or in the spinal cord. Or it can... affect the cerebral arteries and cause them to perform vasoconstriction which is going to decrease cerebral blood flow which is the amount of blood going to the brain tissue which whenever that happens that helps decrease intracranial pressure however the body can only do this up to a certain point and if this pressure continues to build it all it actually gets to the point where the body will start making things worse and will actually lead to what's called Cushing's triad which we're going to talk about whenever we go over our signs and symptoms so now let's discuss cerebral perfusion pressure CPP what is it it's the pressure that pushes the blood to the brain so hence it's going to influence the cerebral blood flow the CBF so in other words in order for blood to get to that brain tissue issue there has to be a proper pressure in place, which is the cerebral perfusion pressure. And what does that pressure have to be in order to get a good amount of blood to that brain? It has to be between 60 to 100 millimeters of mercury. And I would remember that number along with how we remembered the normal ICP. Okay, so when cerebral perfusion pressure falls too low... the brain is not going to perfuse and brain tissue will die so really anything less than 50 of a cpp is bad and we are probably going to lose some brain tissue the brain is not being perfused so since we know what cerebral perfusion pressure is let's talk about how we calculate it how do we figure it out well we use this formula cerebral perfusion pressure is equal to the mean artificial pressure the map minus the intracranial pressure and to figure it out you have to know some things you have to know the patient's blood pressure and what their intracranial pressure reading is and usually you can get this from whatever monitoring system they have in place so let's calculate it out first we have to figure out the map the mean arterial pressure so to do that what we're going to do is we're going to take the diastolic which is 42 and we're going to multiply that by two 42 times 2 is 84. Now we're going to take 84 and we're going to add it to the systolic blood pressure. That's the top number. So it's 90. So 84 plus 90 is 174. Then we're going to take 174 and divide that by 3. And that leaves us with 58. And 58 is our map now we're ready to plug it in so we can figure out our CPP so 58 minus our intracranial pressure is 19 and 58 minus 19 is 39 and this is our cerebral perfusion pressure okay what was that normal number again it was 60 to 100 so this patient CPP is not good at all. It's very very bad and as you can tell when our MAP, our mean arterial pressure, begins to approach our intracranial pressure our CPP dramatically drops which is not good. So now let's talk about some conditions that a patient can experience that can cause increased intracranial pressure and if they do experience these conditions that we're going to talk about in intracranial pressure is a complication that you want to monitor them for and the first one which is very obvious is if they experience any type of head trauma injury to the head like a traumatic brain injury along with a condition that can increase the amount of cerebral spinal fluid and remember the cerebral spinal fluid was one of those important structures of those three that if they increase in volume you can have an increase of intracranial pressure because it plays a role. Roll with ICP. Along with bleeding, a hemorrhage of some type can increase pressure or a hematoma or a condition called hydrocephalus. A tumor in the brain can exert pressure in there along with some type of infection like encephalitis or meningitis. So now let's recap and see what's going on with a patient who experiences one of those conditions we just went over. Say they have a terminal traumatic brain injury. What's going on? Okay, they've hit their head really bad and it has led to increased intracranial pressure. As this pressure in that tight skull is increasing, what's it going to do? It's going to cut off the blood supply to the brain. So you're going to get ischemia because you have a drop in your cerebral perfusion pressure. And whenever you have a drop in that, what happens? You get decreased amount of blood actually going to this brain tissue so your cerebral blood flow is going to decrease and the brain doesn't like this the brain is super sensitive it likes its glucose and its oxygen and all that so whenever that happens the areas of the brain start to become affected and the body's like oh we've got to do something about it that's where that Monroe Kelly hypothesis starts to come in so it tries to help out and one thing it can do is it can ink increased systolic blood pressure. Whenever it increases the systolic blood pressure, it's trying to push more blood to the brain because there's not a lot going there. It thinks by doing that it's going to help. The pressure continues to increase. It's not being alleviated. What happens in the long run that that increased amount of blood pressure going there is going to cause problems? It's going to lead to more increased intracranial pressure, swelling. slash edema in the brain and by this point your patient is going to be probably having some irregular breathing like chain stokes or something where they are starting to retain carbon dioxide and whenever that happens the arteries dilate and this is going to compress the venous system and it's going to limit the amount of blood flowing back to the heart it's just going to stay there so we have blood hanging out in the the brain what's going to happen we're going to have even more swelling and even more intracranial pressure and this keep in mind this is happening over time so when we start seeing this we're going to start seeing some really bad signs and symptoms and if this is not corrected by the point we get to this stage we can have displacement of the brain tissue itself where it's going to herniate in several directions one thing it can do is it can compress down on that brain stem and the brain stem is very important because we have the medulla we have the vagus nerve which controls our breathing or heart rate all that together and eventually it can lead to death so as the nurse we want to know what is that earliest sign and symptom that we can see in that patient who had that traumatic brain injury what they're going to experience if they're going into increased intracranial pressure because we don't want to see them Whenever they've hit this late stage and when they're having these problems So let's look at those signs and symptoms to help us remember the signs and symptoms Let's remember the mnemonic mind crush because literally our mind our brain is becoming crushed Now the first one is M And I wanted it to be that early sign and symptom that you're gonna see in a patient who may be experiencing Increased intracranial pressure and it is mental status changes. This is absolute earliest indicator. So on a test, if you see which of the following signs and symptoms is the earliest indicator that a patient's having increased intracranial pressure, pick something that deals with a mental status change, such as restlessness, being confused, not responding to questions appropriately. So we really want to monitor for that. Okay, I for irregular breathing and patients will experience a type of irregular breathing called chain stokes. And this is where the they it's like cyclic and they'll have periods of hyperventilation and they then be have no breathing apnea where they're not breathing at all and this happens lay on as that brain is swollen so much it's pushed down on that brain sim where it controls our respiratory abilities and the patient isn't having them very well next in for nerve changes to the Optic and Au- motor nerves because in the brain you have your cranial nerves that deal with your pupil reflex, how the eyes move, and all that swelling increased pressure is compressing them so they're not working appropriately. So the patient could have double vision. They can have swelling of the optic nerves. So if you looked in the eyes with the special device that allows you to look inside the eye, you would see that those optic nerves are swollen. And the proper term for that is papilla de... Also, when you're looking at the pupils, you could see either they're really dilated, they're very large in size, or they're very small in size, and they can be unequal, not the same size. Also, they can have what's called an abnormal doll's eye. So if you ever hear doll's eyes, what's that checking for? It's checking for the oculocephalic reflex. So it indicates if there's any damage to the oculocephalic reflex. that brain stem and if you see this it's not good at all so how do you test for it it's done on an unconscious patient and what you would do is open their eyes and you would move the head from side to side and you're looking at the eyes to see if they move in the opposite direction of the side that you've turned their head and if they do move in the opposite side that's a good sign however if they stay in a fixed position this is a bad sign and it's indicative of brain stem and that's a good sign brain stem damage. Next is D for decerebrate or decorticate posturing. Also they can be flaccid. And what do these type of posturing look like? First let's look at decorticate posturing. This is like a flexor type posturing and this is where the arms will be adducted so close to the body with flexion of the arms and then the leg will be rotated internally with the feet. flex. So the patient, the biggest thing that can help you see this if you see it on the patient, look at those arms and see if they have just really flexed them to the core area of their body. And here is Deserebrate posturing. This is an extension type posturing and again you will have adduction of the arms. They'll be close to the body but you will have extension of the arms with pronation and the feet will just be flexed. So this type of posturing that you're seeing right here is actually the worst of the two. So how can you remember these for exams to differentiate between those because I know they can get confusing and how I remember is how my professors taught me and it just really stuck with me. me and I can remember it. Okay, for decorticate, I remember the word core. So what they're doing is they're bringing their arms to the core of their body. So they're going to be flexed inward. And then the opposite of that is decerebrate. And decerebrate has a lot of ease in it. I don't think this word could possibly have any more ease in it. And I remember that my professors taught me the ease represent the extension. So those arms are going to be extended. Hope that can help you out. it helped me during nursing school. Next C for Cushing's triad. Now if you see this, this is a late sign. We don't want our patients to get to this point. And for testing purposes, I would remember the signs and symptoms of Cushing's triad. What are they? Okay, you can have an increased systolic blood pressure. So that top number will be really high. Now why is this happening? Well, remember when we just talked about with our patho, what's happened is that the brain has sense that hey we're not getting a lot of perfusion pressure to the brain so our brain tissue is not doing well so what happens is that the body increases the systolic blood pressure hoping to get more blood flow there now along with that you may see a widening pulse pressure where that systolic blood pressure is going to be high and the diastolic is going to be low so it's going to be a big difference between them for instance we say a normal blood pressure is 120 over 80 it has a pulse pressure of four 120 minus 80 is 40. However, if you have a really high systolic, we'll say 200, and a low diastolic of 20, that pulse pressure is 180. So you see the difference. 40 is pretty low compared to 180. It's wide, it's big. Then you can also see a decreased heart rate and that can be due to we have a lot of brain swelling. So it's herniating out, pressing on that brain stem which has our vagus nerve in it which controls our heart rate so it's decreasing it along with the baroreceptor reflex and this is where the parasympathetic system has been stimulated because of that really high systolic blood pressure so what it does it decreases the heart rate in hopes of bringing that pressure down. Then you can also have decreased abnormal respirations that chain stokes that we are talking about and again that's where you're having compression on that brain sim specifically that medulla that controls our respiratory abilities and so you're getting that irregular breathing. Okay, R for reflex will be positive for the Babinski if you were to test that out on the ball of the foot, the toes, would fan out. U for unconscious, happens in the late parts of this. S for seizures, so seizure precautions, and they may be on anticonvulsant drugs to prevent seizures because that increases intracranial pressure even more. H for headache. E for emesis, like vomiting, usually without nausea, and this can even be projectile vomiting. And then the last part of our mnemonic, D for deterioration. of the motor function. So they can also experience what's called hemiplegia, where they have weakness on one side of the body. Now let's talk about nursing interventions. What are we going to do for the patient who has increased intracranial pressure? Well, our goals include preventing further increasing that intracranial pressure and monitoring their intracranial pressure readings if they have a device that's measuring that, along with providing care to that patient because a lot of... of times they may be unconscious so we have to provide routine in-depth care to that patient who is unconscious because they can't do a lot of things for themselves and to help us remember our nursing interventions I want you to remember the word pressure and whenever I created this mnemonic I wanted it to include what can increase intracranial pressure along with what we're going to do to prevent that and throw the drugs in there and all that so we can remember it with just one mnemonic okay so P for position the head of the bed about 30 to 35 degrees. Also, along with keeping that head midline and preventing any flexion of the neck or hips. And why do we want to do this? Well, we want to promote as much blood return from the brain to the heart as we can. We don't want that blood staying in the brain because if it does, it increases intracranial pressure. So by keeping the position, it helps. Also, keeping the head midline, not flexed because when we flex it, it impedes blood return from the head. Also, the reason with the hips is because it can increase intra-abdominal pressure. We don't want that. So whenever you're moving these patients around in bed, you've got to be really careful that you do this with care because you don't want to cause these things to happen. Next are for respiratory. We want to prevent hypoxia and hyper- hypercapnia hypoxia is a low oxygen level and hypercapnia is too high of a carbon dioxide level in the blood and a normal carbon dioxide level in the blood is 35 to 45 so anything greater than 45 and why is that well when these phenomenons help happen in the body it causes vasodilation and whenever that happens that increases intracranial pressure so that's why we want to prevent that so we will monitor a results closely, watch their oxygen levels, oxygen saturation, and if they need suctioning, we will do that only as needed, no more than 15 seconds because suctioning in itself increases intracranial pressure and we would want to hyper oxygenate them before and after suctioning. And if they are on mechanical ventilation, the PaCO2 with the carbon dioxide level is usually kept between 30 to 35. So look. lower than the normal limits of 35 to 45. And why is that? Well, when we keep those carbon dioxide levels low, it causes vasoconstriction, which decreases intracranial pressure. And it's important to keep the PEEP low, which is the positive end expiratory pressure low, as low as it can be, because if it's too high, it can increase interthoracic pressure, which can increase intracranial pressure. Next, E, elevated temperature. We want to prevent this. We do not want... want them to enter hypothermia because we learned that can increase intracranial pressure along with increasing their metabolic needs. So the reason that this can happen and they're at risk for that is because there could be damage to the hypothalamus which regulates our temperature or there could be an infection or dehydration and that can increase temperature. So as a nurse we want to monitor it very closely and if you have a patient who's unconscious which route should you take the temperature? It's best to either take it rectally tympanically or tympanically. You want to avoid the oral route or axillary. And some nursing interventions include administering antipyretics per MD order, giving cool baths, removing extra blankets, decreasing room temperature, and using like cooling blankets or a cooling system per MD order. Okay, S for systems to monitor. Around the clock, you're going to be doing neuro checks per your facility. protocol. Also, you're going to be looking at the Glasgow Coma Scale. This scale measures their coma level, hence its name, and the best score a patient can score is 15, indicating they're completely with and responsive. Less than a score of 8 is comatose, and a score of 3 would be completely unresponsive. Also, many patients who are being treated for increased intracranial pressure, they may have a system in place to monitor the increased intracranial pressure and drain off cerebral spinal fluid. One of those that's most commonly used is called a ventriculostomy and it's also called an external ventricular drain. And what this does is it monitors the intracranial pressure and it's a catheter that's inserted in the area of the lateral ventricle and it'll drain the ventricle. drain off CSF during increased pressure readings. And as the nurse, you'll want to monitor for increased intracranial pressures reading greater than 20 millimeters of mercury and report that to the physician. And another thing is that patients who have increased intracranial pressure are not candidates for lumbar punctures because it can cause brain herniation. Next is S for straining activities that are avoided and will Prevent vomiting, sneezing, coughing, the valsalva maneuver where you bear down. Keep the environment calm and avoid restraints. Anytime the patient becomes agitated over stimulation, that can increase intracranial pressure. You for unconscious patient care. You'll want to avoid over sedating them because it can mask those early signs and symptoms that intracranial pressure is. happening. Also, you'll want to be watching their lung sounds, listening to those because if they're unconscious, they can't move. So you'll want to roll them, make sure those secretions are not pulling and suction as needed. But remember that increases intracranial pressure. So be careful with that. And they're going to be immobile. So they're at risk for skin breakdown. Their nutrition is at risk. So they'll probably have like a GI tube where you'll have to maintain feedings and you'll want to be checking for... residuals on that making sure that they're having proper gastric emptying where it's usually less than a hundred milliliters always check with your facilities protocol on that they're at risk for renal stone development from where they're laying there and the kidneys aren't able to drain appropriately so a renal stone can form constipation they're at risk for contractures so you'll want to perform that passive range of motion eye care providing eye solution dilutions and ointments to maintain the eye's integrity. They're at risk for blood clots, probably be on blood thinners. You'll want to have SCDs on them, compression stockings to help prevent that. And you'll want to treat them as a patient who is conscious. We don't know if they can't hear, so you want to talk to them and just treat them like they can hear your words. R4 prescriptions. Let's talk about the drugs that these patients may be on. One drug type categories. called barbiturates and this these drugs help decrease brain metabolism so slow the things down in there and help decrease blood pressure which in turn is going to decrease our intracranial pressure they may also be on depending on if their blood pressure is super low or way too high because we want that systolic to be at least 90 but really no higher than 150 so they may be on vasopressors or be given some iv fluids slowly over time to keep that blood pressure up or if they're really high they may be given some antihypertensive because remember we want to maintain that mean arterial pressure because as it gets the same as the intracranial pressure our cerebral perfusion pressure drops so we have a fine line and what's a normal cerebral perfusion pressure 60 to 100 millimeters of mercury also they may be on anticonvulsants because they're at risk for seizures and hyperosmotic drugs which leads me into the next part of our mnemonic. E for edema management. A hyperosmotic drug used a lot of times that we're going to talk about is called mannitol. And what we're going to do, we want to dehydrate the brain because there's a lot of swelling and edema going on in there. And this has to be done very carefully and you have to monitor that blood pressure and renal function. So let's take a closer look at mannitol. Mannitol is a concentrated sugar and it's not for patients who are in uric, meaning they're putting out no urine, or they've had like a cerebral hemorrhage. And what mannitol does is it enters the blood and it's very concentrated and what it does because it's so concentrated it causes the water the swelling that's been pulling in the brain to be pulled into the blood so we can excrete it out through our kidney so it's going to help us dehydrate the brain and decrease that brain swelling which is going to decrease intracranial pressure now the neat thing about Mantol is that it's filtered through the glomerulus which is part of that nephron that filters our blood. However, once it hits the renal tubules, it's really concentrated. It's not reabsorbed, which in turn will cause water and sodium and chloride, those electrolytes, not to be reabsorbed. So it's going to be excreted out. We're not going to have the water going back in the blood or the sodium and chloride. And what can happen with this drug is that you've got to watch out for fluid volume overload or depletion. There's a fine balance between this and this is why it's given carefully in the intensive care unit so the patient can be monitored very closely. So the fluid volume overload you can see why we have that because we have all the swelling that's going in the brain that fluid entering into the blood so if we're not careful we can put too much on their heart it can back up and they can enter in heart failure pulmonary edema so we have to listen those heart sounds Listen to their lung sounds. Are they clear or do you hear crackles which could represent pulmonary edema? Also depletion because we are dehydrating them. They are going to have some signs and symptoms of thirst and dry mouth. That's what we expect because we're dehydrating the brain. So you want to provide mouth care. However, we don't want them to get too dehydrated. So you want to watch that blood pressure. You want to watch their temperature status because remember dehydration can increase risk for fever. You want to monitor their renal function, make sure we're not putting them in renal failure, their urinary output, and their electrolyte status because the whole name of the game is maintaining this negative fluid balance. Some other drugs used are loop diuretics or corticosteroids. And corticosteroids helps because a lot of times proteins start leaking from where we have a breakdown of the brain barrier. And we've learned that Protein plays a huge role with oncotic pressure and water likes to draw to protein which will increase swelling and corticosteroids can help with that. Okay so that wraps up this NCLEX review over increased intracranial pressure. Thank you so much for watching, don't forget to take the free quiz and to subscribe to our channel for more videos.

It is where the pressure that normally resides within the skull has dramatically increased and this is a medical emergency. The patient needs treatment fast because as that pressure builds it can actually lead to brain death. Now how is intracranial pressure created within the skull?

It's created by the cerebral spinal fluid, the CSF, the brain's tissue, and blood. And we can actually measure intracranial pressure whenever we are monitoring a patient who has this condition. They can place special devices either in the lateral ventricle or sometimes in the subarachnoid space and it can tell us what those pressure readings are running.

And a little bit later in the lecture, we will go into detail about those monitoring devices. So what is a normal intracranial pressure? And I would commit this number to your memory. So a normal ICP is anywhere between 5 to 15 millimeters of mercury.

Now, if the pressure increases greater than 20 millimeters of mercury, the patient needs immediate treatment. So remember the number, 5 to 15. 15. That's where we want our patient. Now let's take a closer look at the human skull.

As you can tell it is very hard and it is limited on how much it can really expand when something inside the skull experiences a change that will lead to increased pressure within it. Now inside the skull are three structures that I want you to remember that can alter intracranial pressure because it's going to help us understand Monroe-Kelly hypothesis. along with the treatment and everything for this condition.

So those structures include the brain, the cerebral spinal fluid, the CSF, and the blood within the brain. And in the blue, you can see this is where the cerebral spinal fluid is. It flows around the brain and down through the spinal cord.

Now, intracranial pressure is interesting because it fluctuates and it can increase depending on certain... factors that influences it. So I want you to remember these factors because whenever we're talking about nursing interventions and treatments we're going to go back to these factors and see how we can intervene to help correct this increased intracranial pressure.

So some factors that can alter increased intracranial pressure is body temperature. For instance, hyperthermia. If a patient's running a temperature this can increase intracranial pressure.

Also, oxygenation status especially the carbon dioxide and O2 levels. If our patient is hypoxic, this can increase intracranial pressure, or if their CO2 level is too high, this can cause vasodilation, which increases the cerebral blood flow to the brain and this increases intracranial pressure. Also, body position can.

So as a nurse, we want to make sure we are aligning our patient's body correctly so we don't increase intracranial pressure like keeping their neck midline we don't want it flex and keeping them at a certain angle 30 to 35 degrees also arterial and venous pressure can affect it and anything that increases intra-abdominal and thoracic pressure like vomiting and bearing down or even flexing their hip can increase that pressure in the abdomen which in turn increases intercranial pressure pressure. Now let's talk about the theory on how the body tries to compensate for whenever a patient is experiencing increased intracranial pressure. Well to do that we have to talk about Monroe-Kelly hypothesis.

You really can't talk about intracranial pressure unless you discuss this because it gives us our pathophysiology on how really this condition is happening. So what it says and what it deals with is how the intracranial pressure is affected by those three important structures that we just went over. the cerebral spinal fluid, the brain's blood and tissue.

And these three structures work together to maintain the cerebral perfusion pressure, the CPP. And I want you to remember that term because it's really important whenever we're talking about increased intracranial pressure, and we're going to discuss it in depth here in a moment. So what does this hypothesis say? In a nutshell, what it's talking about, it's saying that if there is an increase in volume of one of those three structures that we just talked about, the other structures that aren't being affected are going to have to decrease. their volume to help alleviate that pressure that is building.

And how does it do this? It can do this by taking that CSF, the cerebral spinal fluid, and moving it somewhere else in the brain or in the spinal cord. Or it can...

affect the cerebral arteries and cause them to perform vasoconstriction which is going to decrease cerebral blood flow which is the amount of blood going to the brain tissue which whenever that happens that helps decrease intracranial pressure however the body can only do this up to a certain point and if this pressure continues to build it all it actually gets to the point where the body will start making things worse and will actually lead to what's called Cushing's triad which we're going to talk about whenever we go over our signs and symptoms so now let's discuss cerebral perfusion pressure CPP what is it it's the pressure that pushes the blood to the brain so hence it's going to influence the cerebral blood flow the CBF so in other words in order for blood to get to that brain tissue issue there has to be a proper pressure in place, which is the cerebral perfusion pressure. And what does that pressure have to be in order to get a good amount of blood to that brain? It has to be between 60 to 100 millimeters of mercury. And I would remember that number along with how we remembered the normal ICP. Okay, so when cerebral perfusion pressure falls too low...

the brain is not going to perfuse and brain tissue will die so really anything less than 50 of a cpp is bad and we are probably going to lose some brain tissue the brain is not being perfused so since we know what cerebral perfusion pressure is let's talk about how we calculate it how do we figure it out well we use this formula cerebral perfusion pressure is equal to the mean artificial pressure the map minus the intracranial pressure and to figure it out you have to know some things you have to know the patient's blood pressure and what their intracranial pressure reading is and usually you can get this from whatever monitoring system they have in place so let's calculate it out first we have to figure out the map the mean arterial pressure so to do that what we're going to do is we're going to take the diastolic which is 42 and we're going to multiply that by two 42 times 2 is 84. Now we're going to take 84 and we're going to add it to the systolic blood pressure. That's the top number. So it's 90. So 84 plus 90 is 174. Then we're going to take 174 and divide that by 3. And that leaves us with 58. And 58 is our map now we're ready to plug it in so we can figure out our CPP so 58 minus our intracranial pressure is 19 and 58 minus 19 is 39 and this is our cerebral perfusion pressure okay what was that normal number again it was 60 to 100 so this patient CPP is not good at all.

It's very very bad and as you can tell when our MAP, our mean arterial pressure, begins to approach our intracranial pressure our CPP dramatically drops which is not good. So now let's talk about some conditions that a patient can experience that can cause increased intracranial pressure and if they do experience these conditions that we're going to talk about in intracranial pressure is a complication that you want to monitor them for and the first one which is very obvious is if they experience any type of head trauma injury to the head like a traumatic brain injury along with a condition that can increase the amount of cerebral spinal fluid and remember the cerebral spinal fluid was one of those important structures of those three that if they increase in volume you can have an increase of intracranial pressure because it plays a role. Roll with ICP. Along with bleeding, a hemorrhage of some type can increase pressure or a hematoma or a condition called hydrocephalus. A tumor in the brain can exert pressure in there along with some type of infection like encephalitis or meningitis.

So now let's recap and see what's going on with a patient who experiences one of those conditions we just went over. Say they have a terminal traumatic brain injury. What's going on? Okay, they've hit their head really bad and it has led to increased intracranial pressure. As this pressure in that tight skull is increasing, what's it going to do?

It's going to cut off the blood supply to the brain. So you're going to get ischemia because you have a drop in your cerebral perfusion pressure. And whenever you have a drop in that, what happens?

You get decreased amount of blood actually going to this brain tissue so your cerebral blood flow is going to decrease and the brain doesn't like this the brain is super sensitive it likes its glucose and its oxygen and all that so whenever that happens the areas of the brain start to become affected and the body's like oh we've got to do something about it that's where that Monroe Kelly hypothesis starts to come in so it tries to help out and one thing it can do is it can ink increased systolic blood pressure. Whenever it increases the systolic blood pressure, it's trying to push more blood to the brain because there's not a lot going there. It thinks by doing that it's going to help. The pressure continues to increase. It's not being alleviated.

What happens in the long run that that increased amount of blood pressure going there is going to cause problems? It's going to lead to more increased intracranial pressure, swelling. slash edema in the brain and by this point your patient is going to be probably having some irregular breathing like chain stokes or something where they are starting to retain carbon dioxide and whenever that happens the arteries dilate and this is going to compress the venous system and it's going to limit the amount of blood flowing back to the heart it's just going to stay there so we have blood hanging out in the the brain what's going to happen we're going to have even more swelling and even more intracranial pressure and this keep in mind this is happening over time so when we start seeing this we're going to start seeing some really bad signs and symptoms and if this is not corrected by the point we get to this stage we can have displacement of the brain tissue itself where it's going to herniate in several directions one thing it can do is it can compress down on that brain stem and the brain stem is very important because we have the medulla we have the vagus nerve which controls our breathing or heart rate all that together and eventually it can lead to death so as the nurse we want to know what is that earliest sign and symptom that we can see in that patient who had that traumatic brain injury what they're going to experience if they're going into increased intracranial pressure because we don't want to see them Whenever they've hit this late stage and when they're having these problems So let's look at those signs and symptoms to help us remember the signs and symptoms Let's remember the mnemonic mind crush because literally our mind our brain is becoming crushed Now the first one is M And I wanted it to be that early sign and symptom that you're gonna see in a patient who may be experiencing Increased intracranial pressure and it is mental status changes. This is absolute earliest indicator.

So on a test, if you see which of the following signs and symptoms is the earliest indicator that a patient's having increased intracranial pressure, pick something that deals with a mental status change, such as restlessness, being confused, not responding to questions appropriately. So we really want to monitor for that. Okay, I for irregular breathing and patients will experience a type of irregular breathing called chain stokes.

And this is where the they it's like cyclic and they'll have periods of hyperventilation and they then be have no breathing apnea where they're not breathing at all and this happens lay on as that brain is swollen so much it's pushed down on that brain sim where it controls our respiratory abilities and the patient isn't having them very well next in for nerve changes to the Optic and Au- motor nerves because in the brain you have your cranial nerves that deal with your pupil reflex, how the eyes move, and all that swelling increased pressure is compressing them so they're not working appropriately. So the patient could have double vision. They can have swelling of the optic nerves.

So if you looked in the eyes with the special device that allows you to look inside the eye, you would see that those optic nerves are swollen. And the proper term for that is papilla de... Also, when you're looking at the pupils, you could see either they're really dilated, they're very large in size, or they're very small in size, and they can be unequal, not the same size.

Also, they can have what's called an abnormal doll's eye. So if you ever hear doll's eyes, what's that checking for? It's checking for the oculocephalic reflex. So it indicates if there's any damage to the oculocephalic reflex.

that brain stem and if you see this it's not good at all so how do you test for it it's done on an unconscious patient and what you would do is open their eyes and you would move the head from side to side and you're looking at the eyes to see if they move in the opposite direction of the side that you've turned their head and if they do move in the opposite side that's a good sign however if they stay in a fixed position this is a bad sign and it's indicative of brain stem and that's a good sign brain stem damage. Next is D for decerebrate or decorticate posturing. Also they can be flaccid.

And what do these type of posturing look like? First let's look at decorticate posturing. This is like a flexor type posturing and this is where the arms will be adducted so close to the body with flexion of the arms and then the leg will be rotated internally with the feet.

flex. So the patient, the biggest thing that can help you see this if you see it on the patient, look at those arms and see if they have just really flexed them to the core area of their body. And here is Deserebrate posturing.

This is an extension type posturing and again you will have adduction of the arms. They'll be close to the body but you will have extension of the arms with pronation and the feet will just be flexed. So this type of posturing that you're seeing right here is actually the worst of the two.

So how can you remember these for exams to differentiate between those because I know they can get confusing and how I remember is how my professors taught me and it just really stuck with me. me and I can remember it. Okay, for decorticate, I remember the word core. So what they're doing is they're bringing their arms to the core of their body.

So they're going to be flexed inward. And then the opposite of that is decerebrate. And decerebrate has a lot of ease in it. I don't think this word could possibly have any more ease in it. And I remember that my professors taught me the ease represent the extension.

So those arms are going to be extended. Hope that can help you out. it helped me during nursing school. Next C for Cushing's triad.

Now if you see this, this is a late sign. We don't want our patients to get to this point. And for testing purposes, I would remember the signs and symptoms of Cushing's triad.

What are they? Okay, you can have an increased systolic blood pressure. So that top number will be really high. Now why is this happening?

Well, remember when we just talked about with our patho, what's happened is that the brain has sense that hey we're not getting a lot of perfusion pressure to the brain so our brain tissue is not doing well so what happens is that the body increases the systolic blood pressure hoping to get more blood flow there now along with that you may see a widening pulse pressure where that systolic blood pressure is going to be high and the diastolic is going to be low so it's going to be a big difference between them for instance we say a normal blood pressure is 120 over 80 it has a pulse pressure of four 120 minus 80 is 40. However, if you have a really high systolic, we'll say 200, and a low diastolic of 20, that pulse pressure is 180. So you see the difference. 40 is pretty low compared to 180. It's wide, it's big. Then you can also see a decreased heart rate and that can be due to we have a lot of brain swelling.

So it's herniating out, pressing on that brain stem which has our vagus nerve in it which controls our heart rate so it's decreasing it along with the baroreceptor reflex and this is where the parasympathetic system has been stimulated because of that really high systolic blood pressure so what it does it decreases the heart rate in hopes of bringing that pressure down. Then you can also have decreased abnormal respirations that chain stokes that we are talking about and again that's where you're having compression on that brain sim specifically that medulla that controls our respiratory abilities and so you're getting that irregular breathing. Okay, R for reflex will be positive for the Babinski if you were to test that out on the ball of the foot, the toes, would fan out. U for unconscious, happens in the late parts of this.

S for seizures, so seizure precautions, and they may be on anticonvulsant drugs to prevent seizures because that increases intracranial pressure even more. H for headache. E for emesis, like vomiting, usually without nausea, and this can even be projectile vomiting. And then the last part of our mnemonic, D for deterioration. of the motor function.

So they can also experience what's called hemiplegia, where they have weakness on one side of the body. Now let's talk about nursing interventions. What are we going to do for the patient who has increased intracranial pressure? Well, our goals include preventing further increasing that intracranial pressure and monitoring their intracranial pressure readings if they have a device that's measuring that, along with providing care to that patient because a lot of... of times they may be unconscious so we have to provide routine in-depth care to that patient who is unconscious because they can't do a lot of things for themselves and to help us remember our nursing interventions I want you to remember the word pressure and whenever I created this mnemonic I wanted it to include what can increase intracranial pressure along with what we're going to do to prevent that and throw the drugs in there and all that so we can remember it with just one mnemonic okay so P for position the head of the bed about 30 to 35 degrees.

Also, along with keeping that head midline and preventing any flexion of the neck or hips. And why do we want to do this? Well, we want to promote as much blood return from the brain to the heart as we can. We don't want that blood staying in the brain because if it does, it increases intracranial pressure. So by keeping the position, it helps.

Also, keeping the head midline, not flexed because when we flex it, it impedes blood return from the head. Also, the reason with the hips is because it can increase intra-abdominal pressure. We don't want that.

So whenever you're moving these patients around in bed, you've got to be really careful that you do this with care because you don't want to cause these things to happen. Next are for respiratory. We want to prevent hypoxia and hyper- hypercapnia hypoxia is a low oxygen level and hypercapnia is too high of a carbon dioxide level in the blood and a normal carbon dioxide level in the blood is 35 to 45 so anything greater than 45 and why is that well when these phenomenons help happen in the body it causes vasodilation and whenever that happens that increases intracranial pressure so that's why we want to prevent that so we will monitor a results closely, watch their oxygen levels, oxygen saturation, and if they need suctioning, we will do that only as needed, no more than 15 seconds because suctioning in itself increases intracranial pressure and we would want to hyper oxygenate them before and after suctioning.

And if they are on mechanical ventilation, the PaCO2 with the carbon dioxide level is usually kept between 30 to 35. So look. lower than the normal limits of 35 to 45. And why is that? Well, when we keep those carbon dioxide levels low, it causes vasoconstriction, which decreases intracranial pressure. And it's important to keep the PEEP low, which is the positive end expiratory pressure low, as low as it can be, because if it's too high, it can increase interthoracic pressure, which can increase intracranial pressure. Next, E, elevated temperature.

We want to prevent this. We do not want... want them to enter hypothermia because we learned that can increase intracranial pressure along with increasing their metabolic needs.

So the reason that this can happen and they're at risk for that is because there could be damage to the hypothalamus which regulates our temperature or there could be an infection or dehydration and that can increase temperature. So as a nurse we want to monitor it very closely and if you have a patient who's unconscious which route should you take the temperature? It's best to either take it rectally tympanically or tympanically.

You want to avoid the oral route or axillary. And some nursing interventions include administering antipyretics per MD order, giving cool baths, removing extra blankets, decreasing room temperature, and using like cooling blankets or a cooling system per MD order. Okay, S for systems to monitor. Around the clock, you're going to be doing neuro checks per your facility. protocol.

Also, you're going to be looking at the Glasgow Coma Scale. This scale measures their coma level, hence its name, and the best score a patient can score is 15, indicating they're completely with and responsive. Less than a score of 8 is comatose, and a score of 3 would be completely unresponsive. Also, many patients who are being treated for increased intracranial pressure, they may have a system in place to monitor the increased intracranial pressure and drain off cerebral spinal fluid.

One of those that's most commonly used is called a ventriculostomy and it's also called an external ventricular drain. And what this does is it monitors the intracranial pressure and it's a catheter that's inserted in the area of the lateral ventricle and it'll drain the ventricle. drain off CSF during increased pressure readings.

And as the nurse, you'll want to monitor for increased intracranial pressures reading greater than 20 millimeters of mercury and report that to the physician. And another thing is that patients who have increased intracranial pressure are not candidates for lumbar punctures because it can cause brain herniation. Next is S for straining activities that are avoided and will Prevent vomiting, sneezing, coughing, the valsalva maneuver where you bear down. Keep the environment calm and avoid restraints. Anytime the patient becomes agitated over stimulation, that can increase intracranial pressure.

You for unconscious patient care. You'll want to avoid over sedating them because it can mask those early signs and symptoms that intracranial pressure is. happening. Also, you'll want to be watching their lung sounds, listening to those because if they're unconscious, they can't move.

So you'll want to roll them, make sure those secretions are not pulling and suction as needed. But remember that increases intracranial pressure. So be careful with that. And they're going to be immobile. So they're at risk for skin breakdown.

Their nutrition is at risk. So they'll probably have like a GI tube where you'll have to maintain feedings and you'll want to be checking for... residuals on that making sure that they're having proper gastric emptying where it's usually less than a hundred milliliters always check with your facilities protocol on that they're at risk for renal stone development from where they're laying there and the kidneys aren't able to drain appropriately so a renal stone can form constipation they're at risk for contractures so you'll want to perform that passive range of motion eye care providing eye solution dilutions and ointments to maintain the eye's integrity. They're at risk for blood clots, probably be on blood thinners. You'll want to have SCDs on them, compression stockings to help prevent that.

And you'll want to treat them as a patient who is conscious. We don't know if they can't hear, so you want to talk to them and just treat them like they can hear your words. R4 prescriptions.

Let's talk about the drugs that these patients may be on. One drug type categories. called barbiturates and this these drugs help decrease brain metabolism so slow the things down in there and help decrease blood pressure which in turn is going to decrease our intracranial pressure they may also be on depending on if their blood pressure is super low or way too high because we want that systolic to be at least 90 but really no higher than 150 so they may be on vasopressors or be given some iv fluids slowly over time to keep that blood pressure up or if they're really high they may be given some antihypertensive because remember we want to maintain that mean arterial pressure because as it gets the same as the intracranial pressure our cerebral perfusion pressure drops so we have a fine line and what's a normal cerebral perfusion pressure 60 to 100 millimeters of mercury also they may be on anticonvulsants because they're at risk for seizures and hyperosmotic drugs which leads me into the next part of our mnemonic.

E for edema management. A hyperosmotic drug used a lot of times that we're going to talk about is called mannitol. And what we're going to do, we want to dehydrate the brain because there's a lot of swelling and edema going on in there. And this has to be done very carefully and you have to monitor that blood pressure and renal function. So let's take a closer look at mannitol.

Mannitol is a concentrated sugar and it's not for patients who are in uric, meaning they're putting out no urine, or they've had like a cerebral hemorrhage. And what mannitol does is it enters the blood and it's very concentrated and what it does because it's so concentrated it causes the water the swelling that's been pulling in the brain to be pulled into the blood so we can excrete it out through our kidney so it's going to help us dehydrate the brain and decrease that brain swelling which is going to decrease intracranial pressure now the neat thing about Mantol is that it's filtered through the glomerulus which is part of that nephron that filters our blood. However, once it hits the renal tubules, it's really concentrated.

It's not reabsorbed, which in turn will cause water and sodium and chloride, those electrolytes, not to be reabsorbed. So it's going to be excreted out. We're not going to have the water going back in the blood or the sodium and chloride.

And what can happen with this drug is that you've got to watch out for fluid volume overload or depletion. There's a fine balance between this and this is why it's given carefully in the intensive care unit so the patient can be monitored very closely. So the fluid volume overload you can see why we have that because we have all the swelling that's going in the brain that fluid entering into the blood so if we're not careful we can put too much on their heart it can back up and they can enter in heart failure pulmonary edema so we have to listen those heart sounds Listen to their lung sounds. Are they clear or do you hear crackles which could represent pulmonary edema?

Also depletion because we are dehydrating them. They are going to have some signs and symptoms of thirst and dry mouth. That's what we expect because we're dehydrating the brain. So you want to provide mouth care. However, we don't want them to get too dehydrated.

So you want to watch that blood pressure. You want to watch their temperature status because remember dehydration can increase risk for fever. You want to monitor their renal function, make sure we're not putting them in renal failure, their urinary output, and their electrolyte status because the whole name of the game is maintaining this negative fluid balance. Some other drugs used are loop diuretics or corticosteroids.

And corticosteroids helps because a lot of times proteins start leaking from where we have a breakdown of the brain barrier. And we've learned that Protein plays a huge role with oncotic pressure and water likes to draw to protein which will increase swelling and corticosteroids can help with that. Okay so that wraps up this NCLEX review over increased intracranial pressure. Thank you so much for watching, don't forget to take the free quiz and to subscribe to our channel for more videos.

Transcript for:Overview of Increased Intracranial Pressure

Transcript for:
Overview of Increased Intracranial Pressure