increased intracranial pressure or icp is when you have an increase in pressure inside the skull and around the brain normal intracranial pressure can be 5 to 15. anything above 20 is abnormal and should be reported now what causes increased intracranial pressure to occur can be tumors trauma like head injury or stroke infection like meningitis or encephalitis all these things will increase the pressure inside the skull and around the brain when the patient has elevated intracranial pressure the number one sign you're going to see is a decrease in the level of consciousness when the patient has a decrease in llc it means the patient can be lethargic they can be confused restless or agitated the best way to measure level of consciousness is with something called a glasgow coma scale and it looks like this here we see that there's three sections behavior response and score under behavior we see something called eye opening what this means if you walk into the patient's room and they open their eyes spontaneously they get a score of four if you walk into the room and they don't open their eyes and you have to call their name and talk to them for them to open their eyes they get a score of three if you walk into the room and you talk to them they still don't open their eyes then you have to apply pain and you can do this with something called a sternal rub a sternal rub is when you rub their sternum causing pain you can also apply pain by doing a trapezius squeeze you can also apply pressure to the supraorbital or the mandibular areas make sure you rotate between sites so you don't bruise them so if the patient opens their eyes after you've applied pain then they get a score of two if you apply pain and they still don't open their eyes they get a score of one now for best verbal response this means the patient is able to answer all three orientation questions correct the three questions being do you know where you are do you know what date it is and do you know who the president is the patient has to get all three correct to get a score of five if they get even one incorrect then they get a score of four and they're considered confused if you ask them a question and then they respond with an appropriate word then they get a score of three an example of this can be like asking them who's the president of the united states and they answer banana that would be considered an inappropriate word and they get a score of three when you ask one of the questions and the patient just responds with sounds and no words then they get a score of two if they don't respond at all they get a score of one for best motor the patient has to obey a command and it can be something as simple as asking them to raise their arm so you can take their blood pressure if they're able to obey a command they get a score of six if they don't obey a command then you have to go straight to pain so when you use the sterno rub to apply pain and the patient finds your hand and moves it away this is called localizing to pain and they get a score of five if the patient just moves their entire body away from the pain this is called withdrawal from pain and they get a score of four if the patient's body flexes inwards this is called decorticate and the way you're going to remember this is that the patient's moves towards the cord they move towards their spinal cord everything flexes inwards if the patient's body extends outwards this is called the cerebrate if you apply pain and there's no response then they get 1. so this gives us a minimum of 3 and a maximum of 15. something important to note is that if your patient has a score of less than 8 you want to make sure you intubate okay so less than eight into bay this is because your patient is considered to be in a coma all right let's get back to the symptoms of increased intracranial pressure the patient can also experience headache vomiting and seizures they can also have eye issues as the pressure keeps going up they can start off with something called ips lateral dilation and this is an early sign of increased intracranial pressure and it's due to compression of cranial nerve number three you will see fixed dilation of the pupil only on the side where the damage is the patient can also have sluggish pupils pitosis which means droopy eyelids blurred vision diplopia and papillaedema which is swelling of the optic nerve if the pressure keeps going up one of the late signs you'll see is something called fixed dilated pupils the patient will also be unresponsive and this is a late sign of very high intracranial pressures as the pressure keeps going up the patient is also going to have motor and reflex issues so they have hemiplegia which means weakness and this tends to be on the opposite side of the injury so if there's injury to the right side of the brain that means that the weakness in the body will be on the left side if the injury is to the left side of the brain then the weakness will be on the right side of the body it's always the opposite side the patient can also have something called a positive babinski's this is when you stroke the lateral side of the sole of the feet causing the toes to either fan down or up normally the toes are supposed to fan down flex down scrunch up this is a normal response but with there's a positive babinski's which is an abnormal response the toes will fan out other motor issues that the patient can experience can be decorticate and decelerate these are very important to know make sure you remember that the corticate is when the patient flexes inward and the cerebral is when the patient extends outward when the patient starts having very high increased intracranial pressures then you'll start seeing changes in vital signs you will see that temperatures increase this happens if there is a hypothalamus injury you'll see a low pulse so below 60 and it will be bounding meaning it's very strong and you can't make it go away by pressing down on it the blood pressure will also be very high the respiratory rate will go down not necessarily down but they'll get something called shine stokes respirations this is when the patient breathes heavily and then they have periods of apnea and this is how that sounds the last vital sign change is something called an increase or widening pulse pressure pulse pressure is going to be the systolic minus the diastolic so for example if the systolic is 120 and the diastolic is 80 that means the pulse pressure is 40. now in a patient that has increased intracranial pressure what will happen is that this number will go up the systolic blood pressure will keep going up getting further away from the diastolic number causing an increase in pulse pressure this is also called a widening pulse pressure because the systolic and diastolic keep getting further apart an easy way to remember all of these vital sign changes is to think of shock because cushing's triad is the exact opposite of hypovolemic shock so let's pretend someone is bleeding out if someone's bleeding out the blood pressure will be low their pulse will be high and their respiratory rate will be also high if someone's having increased intracranial pressure it's exactly the opposite the blood pressure will be high the pulse will be low and the respirations will be low one of the main complications of having high increased intracranial pressure is herniation herniation of the brain happens when the pressure is so high that the brain moves towards the opening of where the brain stem is while there can be many signs and symptoms of this happening including cushing's triad the main sign and symptom is going to be fixed dilated pupils if nothing is done for this patient the patient will die and even if this complication is managed there's a good chance of brain death or severe disability the diagnostics for increased intracranial pressure depend on what's going on because increase intracranial pressure can be caused by head injury or stroke or tumors the main diagnostic is going to be a ct scan the ct scan can reveal what happened during the head injury whether or not there's tumors or if there's any type of bleeding going on inside the brain mris can also be used and they're more specific than ct scans but ct scans are a lot quicker giving us results for immediate intervention one important diagnostic to know is not to do a lumbar puncture or spinal tap this is because this can increase the pressure inside the brain and lead to brain herniation now monitoring icp is done when the glass glacoma scale scores less than 8 and there's an abnormal ct or mri this is done with a ventriculostomy also called an ebd or external ventricular drain this is done by drilling a hole into the skull and inserting a catheter into the brain specifically the ventricles of the brain this is done to measure the intracranial pressure and to assist with csf drainage make sure you remember that a level above 20 requires treatment and you should notify the doctor also because it's a catheter going into the brain there's a risk for infection so make sure you monitor temperatures remember that a fever is anything above 100.4 and signifies infection all right so the nursing interventions for patients with increased intracranial pressure involve positioning make sure you elevate the head of the bed to 30 degrees this prevents the patient from being flexed and increasing the pressure you also want to make sure the patient is in the midline neutral position so make sure they're not flat or in trendelenburgs and make sure they don't flex anything such as flexing their neck or flexing at the hip which is why we place them in 30 degrees semi-folders other interventions you can do is avoid things that increase intracranial pressure like fever having a fever or high temperatures will increase the intracranial pressure also having high co2s in the body so make sure the patient maintains normal co2 levels another thing that causes icp to go up is intra-abdominal pressure such as straining or coughing or flexing shivering sneezing vomiting or suctioning any of these things can cause the pressure to go up one thing about suctioning is make sure you know this is prn do not suction on a schedule only as needed and make sure you pre-oxygen in the patient before you suction them other things that cause increase in intracranial pressure can be seizures pain and environmental stimuli so make sure you take care of the bright lights the high temperatures and the noise you can do this by dimming the lights lowering the room temperature and reducing the noise all right now the medical interventions the main medication that's going to be used for increased intracranial pressure is called mannetal this is an osmotic diuretic that pulls the fluid from the brain tissue and it pulls it into the vascular space now because it pulls fluid into the vessels there's a chance that there will be too much fluid for the heart to pump causing the fluid to back up into the lungs causing pulmonary edema how you know this drug has been effective is through lowering of intracranial pressure if the pressure is within the normal limits of 5-15 then then you know this drug is effective the other way you know this drug is effective is through level of consciousness if we see the level of consciousness go up then we know this drug is working we can do this by seeing if the patient is still confused or restless and we can also see the score of the glasgow coma scale go up other medications that can be used for increased intracranial pressure include hypertonic saline this works in the same way as the mannitol it pulls fluid from the tissue steroids can be used to decrease the inflammation and decrease the pressure the steroid that's most often used is called dexamethasone make sure you do not give this for patients with head injury patients with head imageries do not receive steroids also make sure you add a h2 antagonist or ppi which are antacids to prevent ulcers and gi bleed from the steroid other drugs that are given when a patient has increased intracranial pressure include anti-seizure drugs like phenytoin and phenobarbital make sure you monitor the respirations when patients are in phenobarbital because it is a cns depressant and it will cause respiratory depression the patient can also receive acetaminophen to reduce any fevers because that can increase the intracranial pressure make sure you monitor the liver the patient will also receive sedatives like propofol or opioids like fentanyl or benzoyl diazepines like midazolam all to put the patient to sleep in combination with a sedative the patient can also receive a neuromuscular blocking agent a muscle paralyzer an example of this is cesar curium or the trade name being members alright guys that's everything you need for increased intracranial pressure