Professional Documents
Culture Documents
Kennedy
Cognitive Power - refers to someone’s ability to process stimuli and then to produce a response. It
is a verbal and motor response to the stimulus.
- There are many terms that are used to describe levels of consciousness. The most
important thing is to :
o Confusion - impaired decision making or incorrect interpretation of stimuli
o Disorientation - not orientated to time, person or place or a combination of those.
Usually a person will lose orientation to time 1st, place 2nd and lastly to person.
o Lethargic or drowsy - client will respond slowly, but appropriately, will have limited
spontaneous movement, speech is often sluggish, but will usually arouse to voice or
light touch.
o Obtunded - client arouses with stimulation - must be stimulated to be aroused. They
appear very sleepy, and will easily fall asleep again when not stimulated. Client may
also be slightly disoriented when awakened.
o Stuporous - unconscious. Very difficult to arouse, appears to be in a very deep sleep,
it take a lot of vigorous and repeated stimulation to arouse them. This client may also
be combative when they are awakened. Will usually only follow simple commands.
They may be able to squeeze your hand after much repeated stimulation to get them to
wake up.
o Semi-comatose - client responds only to a painful stimulus. May have purposeful
responses such as grimacing or pulling away from the painful stimulus. (FYI - When
you are looking at a person withdrawing from pain, in order to qualify that they have
actually withdrawn to pain, they have to cross over to the other side of the body. In
other words, if you are applying painful stimulus the client will have to pull their arm
across the midline of the body.)
o Coma - considered unconscious when patient is unaware of self or the environment.
Can last for days, up to months or years. This state might last indefinitely until death.
Client does not open their eyes, has no verbalization, don’t follow commands, no
speech or eye opening. Unresponsive to pain. No purposeful response to stimulus -
even if it is painful. They lack muscle tone (hypotonic). They do not respond to noxious
stimuli purposefully. May see non-purposeful movement in response to stimulus such
as posturing.
o Akinetic mutism - client is unresponsive to the environment - makes no movement or
sound, but may sometimes open their eyes.
o Persistent vegetative state - results from permanent damage to the cerebral cortex.
The client is wakeful, but doesn’t have any conscious thought content. They are
awake but they are not interacting with their environment. They do not have any
cognitive or mental function. Their eyes might follow things reflectively to a noise.
They may withdraw to pain. May have a reflective grasp. Sometimes you may see
some reflective activity, they may swallow or something, they may make some sounds,
like crying or babbling sounds - but no purposeful speech. May have some spasticity in
their extremities. Ex: lady in Florida where the family is in a legal battle.
- Patho:
o Causes:
• Neurologic (head injury or stroke)
• Toxicalogic (drugs, ETOH)
• Metabolic (DM, Renal Failure)
- Involves disruption in:
o Cells
o Neurotransmitters of the brain
• Neuron damage or an alteration in the neurotransmitters can interfere with your
impulse transmission and therefore that is why you see slowed responses and
inability to follow commands because the nerve impulse transmission is altered.
o Structure / anatomy of the brain
• There might be edema, tumor or trauma that has actually damaged the brain tissue.
Therefore, you cannot get the nerve impulses traveling correctly through the brain
and the communication between the brain and rest of the body.
o (Or combination of them). If any of these things are disrupted, and you can’t have normal
nerve impulse transmission, you will see slowing in responses and LOC will be altered.
Total 3 - 15
When you are assessing this, say you have a client come in who has had a stroke and has
hemiparesis (weakness on one side). With the Glascow Coma Scale, we would use their good
side to determine best motor response.
- Medical management:
o Obtain and maintain patent airway (this is the #1 thing).
o You want to compensate for their loss of protective reflexes (gag reflex, cough reflex,
corneal reflex, the blink reflex). So if the person has a decrease in LOC, we need to
compensate for their Loss of reflexes.
o Monitor CV status
o Monitor VS
o Nutrition and hydration (may have to be achieved thru tube feedings, IV therapy - if the
client is unconscious and unable to eat or drink).
o Determine and treat the cause – so we can hopefully reverse what is causing the
alteration in LOC
o With the client with Altered LOC, we have to compensate for whatever their deficits are.
When we are talking about caring for the client with altered LOC – what we are really
focusing on is that unconscious client that is in the bed, unable to care for themselves.
You really have to look at where they are and what they are able to do. If they have lost
their protective reflexes (gag reflex, cough reflex, corneal reflex), then we have to
address all of these things in their care.
- Nursing assessment:
o Assure that client is at the highest level of alertness, otherwise you will not get a
true picture of what their true neuro status is. So the 1st thing you want to do is to
make sure that they are at their highest level of alertness. This will give you a good
baseline that you can go on throughout the day.
o Have a parent/relative present when assessing a child (if you have a peds client) - they
will respond better and will be more likely to follow commands and be cooperative if the
parent or someone they are comfortable with is present.
o Verbal response
• Orientation level (to person, place and time) – ask them questions like what year it is,
who is the president.
• Document if you are unable to assess verbal response (intubated). Client may be
alert enough, but unable to speak because they are intubated. In this case, you
would chart that they are able to follow verbal commands, and motor commands, can
blink their eyes, but are unable to speak due to ET tube.
• *Verbal response is something that you are able to assess as soon as you enter the
clients room, before you ever really approach the client. You are looking at when you
go in and say “good morning, how are you” - you are expecting a verbal response.
This is something that you can assess pretty quickly with the neuro client. She finds
that sometime the clients are offended when you ask then if they know who or where
they are, so she just tells them when she walks in she will just tell them that she has
to ask them a few silly questions. This way they don’t think that you think they are
crazy or confused - just tell them that you have to assess this.
o Alertness
• Eye opening to command or stimulus
• A patient with a severe neurologic dysfunction cannot open their eyes.
o Motor response
• Purposeful, spontaneous, is it to stimulus? What kind of movement is it? Do they
withdraw purposefully? It is considered purposeful withdrawal to a stimulus if they
can cross to the other side of the body with the extremity. So if you if you apply nail
bed pressure and they withdraw over the midline to the other side of the body - this is
considered purposeful. Document whether the strength is equal on both sides. We
check muscle strength by having them push our hands with theirs (push and pull). If
they are in the bed lift their leg up off the bed with your hands pressing down on it.
• If unconscious, you are going to have to check by applying a painful stimulus. We do
this by applying pressure to the nail beds. Do not do anything to bruise the client.
You might have to kind of pinch the inside of their forearm. Do not ever put
hemostats on the client to pinch them. If they do not respond to something that is not
going to bruise them, then just document the patient as “unresponsive to painful
stimuli”. Bruises are very difficult to try and justify to the patient’s family.
• Never apply painful stimulus to an alert client (not even on their paralyzed side). Just
do a tactile stimulus – “Can you feel me touching your arm?” If they are alert do not
pinch them to get them to respond.
• It is considered withdrawal to a noxious stimulus when the patient crosses the
midline as a response to the stimulus.
• Posturing - you might see posturing in an unconscious client in response to a
stimulus. It is non-purposeful usually in response to a noxious stimulus. It might be
pain. It might be an immobile client that we are trying to turn. The client might be
coughing. There are 2 types of posturing that we look at:
Decorticate (indicates damage to cerebral cortex). What you will
see with this is internal rotation (adduction) and flexion of the upper extremities;
the lower extremities are also internally rotated and plantar flexion. Pictures are
in the book on page 1852. A good way to remember this is that it is toward the
core of the body.
Decerebrate (indicates deeper and more severe brain
dysfunction and tissue damage). What you will see with this is extension and
outward rotation of the upper extremities. You will still see plantar flexion of the
feet. This is worse than decorticate. A person with decerebrate posturing has a
poorer prognosis than one with decorticate.
You see plantar flexion of the feet in both of these. A good way
to remember decerebrate is that it has a lot of “e” in the word so think about
extension. They extend their arms out and externally rotate.
• Flaccidity (worst neuro finding). Even worse than either of the 2 types of posturing is
total body flaccidity. This is the worst neuro finding. They are flaccid - even to painful
stimulus. This is considered a more grave finding than either of the posturings.
Especially if you have a client that has progressed from decerebrate posturing to total
body flaccidity, they have absolutely no response, this is a bad sign.
- Protective reflexes (if there is no response to pain, we need to start looking for protective
reflexes)
o Corneal reflex (must protect if they can’t blink). Use a wisp of cotton and look for the
blink reflex. If the client does not have an intact corneal reflex, it is one of our
responsibilities to protect the eyes. Be careful not to cause corneal abrasion while
checking for this reflex. The corneal reflex protects the eye.
o Gag reflex - it is very important to see if the client is able to protect their airway against
aspiration - whether they will be able to swallow or not. Use a tongue blade at the back
of the oropharynx. The gag reflex protects the airway.
o Cough reflex – see if they are able to cough
- Facial symmetry (asymmetry may indicate a stroke or pressure on one side of the brain,
facial paralysis)
- Neck (is it stiff) – a stiff neck can indicate infection (like meningitis) or brain hemorrhage.
This might be some of the underlying cause of alteration in LOC.
- DTR (deep tendon reflexes) - absent if in coma or paralysis. If paralysis is on one side - the
DTR would be asymmetric. They are going to be hyper-reflexive on that weak side.
- Pathologic reflexes (Babinski reflex) - stroke the bottom of their foot starting at the heel and
you go up. What do you expect the adult toes to do? We want them to curl in. In a baby
under 18 months, they will fan out. If you have a client who is over 18 months old and they
have a (+) Babinski an their toes fan out, then this is a sign of neurological damage.
- Abnormal posturing (Decorticate, Decerebrate - this is in response to a stimulus)
Nursing diagnosis depends on the cause of the altered LOC and the severity.
CP:
- Respiratory distress or failure (from loss of protective reflexes)
- Pneumonia (from loss of protective reflexes)
- Aspiration (from loss of protective reflexes)
- Pressure ulcer (from being immobile)
- DVT (from being immobile)
- Hazards of immobility
Interventions
- The overall goal is to compensate for the client’s loss of protective reflexes.
- If you have a client who is unconscious and requires total care, they are dependent on you
and other staff to meet their every need. Your nursing care and the quality of your nursing
care may be the difference between life and death for these clients. So if you have a client
who is unconscious or has altered LOC, you need to make sure that you are compensating
for all of the losses that they have. You need to give them the best potential to give them a
good outcome.
- Maintain airway:
o Lateral or semi-prone positioning - DO NOT PLACE AN UNCONSCIOUS CLIENT FLAT
ON THEIR BACK!! When you lie a client on their back, the tongue moves back and it
can occlude the airway and epiglottis. You want to have them on their side so that the
tongue falls forward and the oropharynx is open. Also if they vomit, it may help them to
prevent aspirating.
o Frequent mouth care & suctioning - to remove secretions.
o Elevate HOB 30 degrees - helps prevent aspiration and drain respiratory secretions.
o Auscultate breath sounds q 8 hrs - to check for any abnormal lung sounds. They may
develop if they aspirate. They may develop pneumonia.
o May need intubation - to protect the airway - this puts them at RF pneumonia and other
respiratory complications.
- Achieve thermoregulation:
o Client with altered LOC may have a high temp. they may have increased ICP that is
causing a high temp., it may be from an abnormality in their brain stem, it may be from
an infection, a drug reaction, it can be from several different reasons that they might be
running a temp.
o (no oral temps - tympanic or rectal only - if not conscious). Axillary temp is the least
accurate way to get the temp - it is better to do a rectal temp. Do not do a rectal temp
with increased ICP.
o Things that we can do:
• Adjust environment - make the room a little bit cooler (app 65 degrees). Cover the
client with just one sheet. Sometimes the client may be unconscious and my have 5
blankets on and the room is 70 degrees - this is too warm for them. Be careful
about how much cover you are putting on them.
• Administer antipyretics (Tylenol, ibuprofen)
• Cool sponge baths, cooling blankets (try to do this slowly - if they are running a
temp, you don’t want to ice them down and drop their temp very fast because
shivering is very dangerous for a client with increased ICP
Box theory - think about the brain as a large closed box that can’t expand. Actually this is the
cranial vault. The cranial vault is the skull and all of its contents. Under normal conditions it is
already full. It can not expand. Within the brain, you have 3 components:
Brain - 85%
Blood - 7%
CSF - 8%
- Within normal circumstances, this is within the cranial vault - it is full. These contents have
to remain fairly constant or the ICP will increase. If there is an increased amount of blood or
CSF or you have brain tissue swelling or edema, any of these 3 things can cause an
increase in pressure within the cranial vault.
- The body does try to compensate for some changes. The ability for your brain and your
body to adapt to this is very limited. It is limited because of this very rigid box that the
contents are in. The cranial vault does not do very well with changes in the ICP - other than
just small changes. It does not have very good chance to adjust at all.
- ICP is defined as the force exerted by the brain, blood, and CSF within the skull.
- If one component increases then you will have increased ICP unless another component
decreases. In order to maintain a normal ICP, if you have increase in one component, then
something else has to decrease. You have 100% - it is already full within the cranial vault.
(Monroe-Kelline hypothesis)
- Usually, pressure remains in a state of equilibrium under normal circumstances - your body
kind of autoregulates the pressure. Normal fluctuations do occur, but these fluctuations are
slight and last only for a short period of time. Ex: When you sneeze, you increase your ICP.
If you stand on your head - it increases the ICP - this is why it is so uncomfortable. Your
body is telling you to hurry up and get up.
- Normal fluctuations do occur (sneezing, BP changes, O2 and CO2 levels, Valsalva
maneuver)
- BP changes - usually your body can regulate itself. There is either vasodilation or
vasoconstriction to maintain that same ICP.
- Increased abdominal pressure the Valsalva maneuver - increases the ICP.
- Normal functions do occur (sneezing, BP, O2, and CO2)
- Compensation is very limited - the body can compensate for slight changes but only for brief
periods.
- NORMAL ICP IS 10-20mmHg!!!!! This is measured by looking at the pressure of the CSF
within the brain.
- Usually the way that the body compensates for Increased ICP is by changing the CSF
volume or the blood volume within the brain. CSF is the easiest thing for the body to
displace and get rid of. When you have increased pressure, this is one of the first thing that
changes.
2- Metabolic autoregulation:
o Vasoconstriction and vasodilation of blood vessels respond to O2 and CO2
levels. If you have an increase in CO2 - blood vessels dilate in an attempt to
get more O2 to the brain (more perfusion). If you have an increase in O2
(hyperventilation) - the blood vessels constrict.
These mechanisms work in an attempt to maintain the constant cerebral blood flow. They do NOT
directly reduce the ICP. This is just a response to mechanisms in the body (BP, CO2 levels) that
the body uses to try to protect the brain and maintain a constant blood flow thru the cerebral
vessels.
EX:
BP - 100/60
ICP: 25
- Compensation:
o Most compensation for Increased ICP is accomplished thru Cerebral Spinal Fluid
regulation. (It is the easiest way for the body to compensate for increases in ICP). This
is done in 3 different ways in dealing with CSF.
• Decreased production of CSF – the body is so intricately designed that it can detect
the changes in intracranial pressure and slow down the production of CSF (body
does this 1st.)
• Increased absorption (thru the chorionic villi - this is a normal physiologic process
and it will try to speed up to try to increase the absorption of CSF and decrease the
production)
• Displacement (there are 2 areas (pockets) at the base of the skull around the spinal
cord called foramens that CSF can be displaced to in the presence of increased
intracranial pressure).
• These are 3 things that your body does to try to compensate for increased ICP - it is
a SHORT FIX. It is not going to stop the cause or the problem. After that small ant of
displacement is done, your body can only slow production so much. You need a
certain amt of CSF circulating in the brain to maintain function. These are just some
ways that are slow and minor changes in ICP can be compensated for.
o The body compensates best for increased ICP when:
• When the volume changes are very small (example with a small intracerebral
hemorrhage your body would be able to compensate better as opposed to a large
intracerebral hemorrhage) &
• When changes occur over longer periods of time (rather than a very rapid change in
ICP). If you have a slow hemorrhage, your brain can compensate better than with a
rapid hemorrhage and severe brain trauma.
• So compensation is best when there are small changes over longer periods.
o if compensation can’t be achieved thru these means - CSF regulation and
displacement then:
• Cerebral blood flow becomes compromised and you begin to decompensate
- Decompensation:
o Autoregulation mechanism failure (fail to regulate the increased ICP). The cerebral
blood vessels have done all that they can to maintain perfusion. The CSF has been
displaced and reabsorbed and the production has been slowed all that it can. The body
is overwhelmed and you develop decompensation.
o Venous compression and the blood vessels collapse with continued arterial blood
flow to the brain leading to increased ICP and decreased Cerebral Perfusion (at 1st you
will have venous collapse with the arteries still patent and more blood being sent to the
brain with no where for it to go and no way for it to drain.
o Verebral ischemia and infarction eventually result
o Cushing’s triad (very grave sign of ICP) will then result eventually with increased ICP.
It is characterized by:
• bradycardia (slow, bounding pulse)
• HTN (usually just the SBP is increased - the DBP remains constant- this is how it
widens the pulse pressure - the pulse pressure is the difference between SBP and
DBP). With late signs, you may see both the SBP and the DBP increased.
• Bradypnea - this part of Cushing’s Triad is a very common thing in constantly
increasing ICP. You will see all kinds of resp changes and irregularities - depending
on the area that is being compressed.
o Herniation will occur without intervention
When you think if increased ICP - you need to think of widened pulse pressure, bradycardia and
usually bradypnea.
DECOMPENSATION
CYCLE
“killing itself off”
Vasodilatation
- Decompensation Cycle:
o When you begin to decompensate, you have decreased cerebral blood flow. This
leads to cerebral hypoxia (from decreased O2 b/c there is a decrease in blood flow). In
addition to the decreased O2, you have increased CO2 and decreased pH which leads
to acidosis. This then leads to vasodilation b/c your body is still trying to compensate. It
vasodilates b/c the brain is saying “I need more O2 up here - I don’t have enough O2
and I have too much CO2 and I need more circulation”, so you will have vasodilation of
the cerebral vessels. This further complicates the problem - it leads to more cerebral
edema. You have too much fluid up there, too much in the intravascular and often times
too much in the intracellular and the extracellular - TOO MUCH FLUID!! This leads to
edema. This leads to increased ICP. This leads to restriction of blood flow. You get into
this vicious cycle where the ICP just continues to increase and increase and it causes
your body to think it is compensating - but it is really decompensating. This leads to
further neuro damage and further increased ICP. You go around and around in circles.
o The increased ICP will invariably lead to either herniation (will occur with further
increasing ICP) or cessation of cerebral blood flow. When you lose blood supply to the
brain, this is not good.
o Decompensation leads to:
• decreased cerebral blood flow
• cerebral hypoxia
• acidosis
• vasodilation
• cerebral edema
• increased ICP
• herniation or no cerebral blood flow (if not treated)
- Diagnostic evaluation:
o CT – this is pretty much a given test that is performed first
o MRI – helps you look a little bit more specifically at different structures and see what
is going on a little bit better
o PET Scan – looks at brain functions, it actually looks at the brain as it is functioning.
o Trans Cranial Dopplers - (checks blood flow going to the brain)
o LP (lumbar puncture) is avoided......Why? It causes a risk for herniation.
• If you puncture the lumbar space and it drains real fast, you will have rapidly draining
CSF. What is going to happen to the brain contents and tissue? It is going to fall
down and be decompressed and cause herniation. So avoid an LP in a person who
may have increased ICP or if it is suspected.
The brain stem controls respirations, pulse. It controls our ability to live essentially. So if you lose
circulation to the brain stem, you are no longer able to have a pulse or to maintain your
respirations,
- Brain Herniation:
o Shifting of brain tissue from high pressure to low pressure thru openings in the rigid
dura results in brain stem compression and cerebral blood flow cessation. Cerebral
blood flow stops because of the brain compression on the structures and blood vessels.
FYI -- The dura is the rigid tough out covering of the brain, there are folds in that dura
within the brain itself. It kind of separates parts of the brain.
o Brain contents will either shift downwards or sideways - depending on the cause if
the increased ICP. If you have a lesion or a hemorrhage on one side- you may see a
sideways shift in the brain. If it is generalized increased ICP, you may see the brain shift
downward onto the brain stem.
o Brain stem herniation can occur due to pressure on the brain stem and can cause
cessation of blood flow to the brain and it further increases the pressure and leads to
herniation.
o A skull fracture can cause a herniation - it is not the most common type of herniation,
but it can occur. What do you think happens to the brain tissue when it is pushed thru
the bony edges of the skull fracture? You have severe tissue damage just from it being
pushed outward against the bony surfaces.
o You have 2 major areas that separate the brain and that you can have herniation
thru.
o Anything that starts above the tentorium, is referred to as a supratentorial herniation.
o Then below the tentorium - it is referred to as an infratentorial herniation.
o The foramen magnum is a hole at the base of the skull where the brain and the
spinal cord meet.
o The cerebellum tonsil??? it is part of the cerebellum. It can push thru the rigid bony
skull.
o You can have a supratentorial herniation that can lead to an infratentorial herniation -
it is just going to follow gravity and go to an area of lower pressure. So the
supratentorial herniation presses the brain tissue downward and it can lead to the
cerebellum tonsil herniation. It can lead to further brain tissue herniation.
o Your optic nerve, the cranial nerve that controls your pupil dilation is right at the
tentorium - this is why when you start to see pupil dilation - fixed dilated pupils - you
know that you have trouble - you have brain stem herniation. What does the brain stem
control? Everything - heart rate, BP, resp rate, temperature, etc. If you have brain stem
damage or herniation, your respirations and pulse will stop. If you have brain stem
damage and it herniates thru the foramen magnum.
o the most common type is the when you have parts of the temporal lobe that is
pushed down into the tentorium - this can lead to the brain stem being herniated - it is
pushed down thru the bony layer??? b/c the brain tissue that is being pressed on has to
go somewhere.
Remember we said that the 3rd cranial nerve controls pupil constriction. So if you have pressure
there that has caused that pupil to be fixed and dilated and no longer reactive. Then you have
major brain stem involvement.
FYI -- If you have a client with increased ICP and you start seeing their urine output changing, you
might want to consider that it might be Diabetes insipidus or SIADH.
- Control Fever: (fever increases the metabolic demands of the brain which can further lead
to increased ICP. So we do need to keep them thermoregulated. But you must be careful to
avoid shivering - it further increases ICP.
o antipyretics
o cooling blankets
o avoid shivering (increases ICP)
- Maintain O2: (this should be number one, because our ABC’s are first)
o monitor ABG’s and O2 sats
o give O2
o Hyperventilation may be used to keep them adequately oxygenated and not only
cause vasoconstriction, but mainly to prevent vasodilation. This prevents the CO2 levels
from rising.
- Nursing Diagnosis
pg 1861
o All of the diagnosis we talked about for altered LOC will apply here plus:
o Ineffective airway clearance RT diminished protective reflexes (cough, gag)
o Ineffective breathing patterns RT neuro dysfunction (brain stem compression,
structural displacement)
o Ineffective cerebral tissue perfusion RT the effects of increased ICP
o Deficient fluid volume RT fluid restriction
o RF infection RT ICP monitoring system (fiber optic or intraventricular catheter)
- Other relevant diagnosis are included in the section on caring for pts with altered LOC
o Ineffective airway clearance RT altered LOC
o RF injury RT decreased LOC
o FVD RT inability to take in fluids by mouth
o Impaired oral mucous membranes RT mouth-breathing, absence of pharyngeal
reflex, and altered fluid intake
o RF impaired skin integrity RT immobility
o Impaired tissue integrity of cornea RT diminished or absent corneal reflex
o Ineffective thermoregulation RT damage to hypothalamic center
o impaired urinary elimination (incontinence or retention) RT impairment in neuro
sensing and control
o Bowel incontinence RT impairment in neuro sensing and control and also RT
transitions in nutritional delivery methods
o Disturbed sensory perception RT neuro impairment
o Interrupted family processes RT health crisis
- CP / potential complication:
o Brain stem herniation
o Diabetes insipidus
o SIADH
- Interventions:
o Observation
o Patent airway
o Good breathing pattern
o Good cerebral perfusion
o Negative fluid balance
o Prevent infection
o Monitor and manage ???? tape
o ICP
o Secondary complications
WHY? INCREASED INTRACRANIAL PRESSURE
1. Frequent neuro checks. Why? Change in neuro checks is early indication of increased ICP,
establish base line, look for improvements in LOC, Monitor chgs in LOC. The 1st sign of a change
in neuro status is change in LOC.
2. Drug induced comas. Why? Decreases cerebral oxygen demand, Decrease all metabolic
demands, decreases the amt of body activity that is needed, helps with healing to improve the ICP.
If you have a severe head injury, they will automatically intubate, mechanically vent and put you in
a drug induced coma.
3. Avoidance of Valsalva maneuver. Why? Straining increases ICP (bowel/ bladder). To avoid
constipation with a client, give them stool softeners - these clients do not really need an enema or
fecal disimpaction - all of this will lead to increased ICP. Avoid constipation and fecal impaction.
4. Administer Lasix. Why? Decreases circulating volume if Mannitol doesn’t cause them to
diuresis the way they need to, decreasing ICP. They will have an indwelling cath so that you can
monitor their I&O very closely.
6. Seizure precautions. Why? Increased ICP can cause seizures, this further increases ICP.
Prevent injury, prone to seizures. If they brain tissue becomes irritated, they may have a seizure.
Increased pressure can irritate brain tissue and cause seizures. If the reason for the increased ICP
is infection or hemorrhage, those can be very irritating to the brain tissue. Pressure on internal
structures can cause them.
7. Elevate head of bed. Why? May aid in clearing secretions and improves venous drainage of
the brain. (20-30 degrees). It helps to decrease ICP. If you have a client lying flat on their back,
that increases the blood flow. Elevating the HOB promotes venous drainage. The blood vessels
drain the blood back down so that it decreases the ICP. It also helps with the resp secretions so
that it can help to prevent aspiration.
8. Careful regulation of IV fluids. Why? Prevent rapid infusion which can lead to increased ICP,
Don’t want to overload (fluid) – it causes increased ICP due to intracranial blood volume, you want
to keep them a little bit dehydrated.
9. Neck in neutral, midline position. Why? To promote venous drainage. Extreme rotation And
flexion are avoided due to compression or distortion of jugular veins which Increase ICP. No
pillows (affects veins and arteries; flexes the neck). You don’t want to obstruct the jugular veins by
having their head in a lateral position. If they are unconscious, it is okay to turn them on their side -
but you want the head and neck midline in relation to the body, you don’t want it turned to the side.
10. Administer oxygen. Why? Provide adequate oxygen to the brain. Increased ICP results in
Decreased oxygenation. Increase oxygen; decrease carbon dioxide. Getting enough O2 prevents
vasodilation and keep the vessels partially constricted. It also saturates the RBCs so that you get
plenty of O2 to the brain and maintain the perfusion that you have.
11. Administer osmotic diuretics. Why? (Mannitol) dehydrates the brain and reduces cerebral
edema. Dehydrates the brain. Pulls fluid from the edema to the tissue. Decreases cerebral edema
and puts it into the intravascular space.
12. Passive range of motion? Why? Prevents contractures. Small changes in position can
Increase ICP. Prevent pneumonia (No active ROM). To prevent contractures and joint deformity.
Even if the client is conscious, you don’t want them doing a lot of activity - you don’t want active
ROM where they are have to put pressure and stress on their body. You want to do everything
passively an have them on complete BR with the HOB elevated. You also want to decrease stimuli
in the client with increased ICP. The stimulus can lead to agitation and an increase in ICP.
13. Turn and deep breath. Why? Prevents Valsalva maneuver & coughing. Increases ICP. Risk
for respiratory complications which can lead to pneumonia and change in oxygen and carbon
dioxide levels. Prevent pneumonia, increase gastric motility, decrease skin irritation and
breakdown, increase circulation. It also gives your client a positional sense in the bed even if they
are unconscious. No coughing - this will increase the ICP. You do not need them to initiate a
cough.
14. Administer corticosteroids. Why? Reduce edema surrounding brain tumors when tumor is
cause of ICP. They work but we don’t know why. Reduces cerebral edema and thereby decreases
ICP.
15. Treat elevated temperatures. Why? Prevents increase of temp, because fever increases
cerebral metabolism and rate at which cerebral edema forms. Usual methods of temp control
(Tylenol, etc) may not work. May need to pack groin area in ice or use cooling blankets (set
blanket 2 degrees of desired temp.) Do not want the patient to get too cold – this causes them to
shiver. If they shiver they give Thorazine.
16. Restrict fluids. Why? Reduces amount of circulating volume, decreasing ICP - you do not
want to supply the brain with more fluid than you have to. Fluid overload increases ICP.
17. Check stools for occult blood. Why? Steriods increase the chances of GI bleed. If the client is
on a corticosteroid, they need to also be on a H2 antagonist. This will prevent the GI irritation.
18. Administer anticonvulsants. Why? Prone to seizures. A seizure would not be a good thing in
a client with increased ICP. You need to prevent them from occurring. Even b/4 they have the 1st
seizure, b/c they are at risk, you will see them put on anti-convulsants to prevent them.
19. Monitor intake and output. Why? Monitor hydration status and kidney function. Even though
we are trying to restrict fluids, you don’t want to dehydrate them completely. Assess their hydration
status, but also, look for increased UO (diabetes insipidus), decrease in UO (SIADH)
20. No trendelenburg. Why? Decreases venous drainage and increases ICP. May use modified
trendelenburg if pt is “shocky”.
21. Monitor electrolytes. Why? Monitor dehydration status due to meds and fluid restriction. If
they are on Mannitol or Lasix, it will deplete their electrolytes. (Na+ and K+). If they have diabetes
insipidus or SIADH, you will need to monitor their Na+ levels.
22. No question
23. Keep blood pressure normotensive. Why? Prevent increased ICP. Keep brain perfused.
Increased BP leads to further increasing ICP. Decreased BP leads to inadequate perfusion to the
brain. You want them to have adequate brain perfusion without increasing the ICP.
24. Monitor BUN/ Creat. Levels. Why? Monitor kidney function due to dehydrating care. You
need to know their renal function b/4 you give them the diuretics. You are expecting them to
diurese, if their kidneys are not functioning properly, they will end up in fluid overload.
25. Monitor blood gas values. Why? Monitor oxygen and carbon dioxide levels. Monitor for
complications such as pneumonia. Increased CO2 will lead to vasodilation which further leads to
increased ICP, and increased O2 will lead to vasoconstriction.
26. Continuous intracranial pressure monitoring. Why? Monitor for changes. You need to have a
base line - you need to get it when they are 1 st admitted. You want to be able to detect the early
changes. The ICP monitor can detect early changes in the ICP. It measures the effectiveness of
the tx. You have done all of tese things to reduce the ICP - you need to know if it is working.
27. Administer stool softeners. Why? Prevent constipation. Prevent straining. Prevent Valsalva
maneuver. No enemas or fecal disimpaction if ICP is increasing rapidly or if it is increased
28. Ventriculostomy. Why? Allow for drainage of CSF. Decrease ICP. Overflow valve. Can
obtains CSF samples, instill ABX, measure ICP. Careful not to contaminate - big RF infection. Must
keep it sterile. If you have a client who has a ventriculostomy drain (gravity) - normally what
happens is that the MD orders a specific pressure setting. You have to use some sort of level to
level the insertion site of the ventriculostomy (it is usually just above the ear in the temporal
area???). you will level this with a device. It is just a gravity drain, so as the pressure increases to
a certain amt, then the CSF will drain into the collection system. If the level of the bed is moved
(elevate the bed to chest level so that they can change the pt), it is going to drain out too fast. If the
level of the bed is adjusted and their head is below the level, it won’t drain. It probably won’t go
back into the collection container - it just won’t drain. You need to educated anyone coming into
the room about this (family, staff, assistants, anyone that is dealing with the client). Do not move
the client unless there is a nurse in there also adjusting the ventriculostomy system. Be sure that
whatever the orders are for the pressure reading that you understand this and are very comfortable
taking care of it and taking care of the client. You need to have good understanding of this specific
drainage system, what it is supposed to be set at, how to level it, be familiar with the device b/4
you take care of the client.
29. Intracranial surgery. Why? Correct underlying problem (tumor, hemorrhage, you might also
get a craniectomy where part of the skull is removed to allow for expansion of the contents in the
cranial vault)
With the craniectomy, the bone flap may be surgically implanted in the abdomen to keep it sterile
and keep it within the body tissue. It will look like a huge pulsating fontanel b/c a pc of the skull will
be missing. This is definitely a safety issue - you would not want to put any pressure on it - it is
brain tissue. No pressure on it, don’t turn them to that side and be very careful not to bump their
head.
30. Nothing snug around neck. Why? Prevent increased pressure on jugular veins which
increase ICP. It will decrease the venous drainage and increases ICP.
31. Avoid extreme hip flexion and prone position. Why? Avoid increased intra-abdominal and
intra-thoracic pressure which can increase ICP. Increased abdominal pressure increases the ICP.
32. Assist client to move in bed. Why? Slight changes in position can increase pressure and
increase ICP. Prevent valsalva. It decreases the demands on the client and reduces the RF
increased ICP by turning in bed and increasing the intra-abdominal pressure and trying to move
around in bed - you need to assist them.
33. No restraints. Why? May fight restraints. This leads to straining which increases ICP and BP.
Pad side rails. Keep bed in low position with side rails up. It increases agitation and increases the
ICP. You need to avoid this - do the least restrictive thing possible.
34. Decrease anxiety level and avoid emotional upsets. Why? Anxiety and stress increase
cerebral metabolism and increase ICP. You want to decrease anxiety, agitation and stress.
35. Suction as needed to maintain clear airway. Why? Transient elevations of ICP. You have to
maintain a clear airway - you have to prevent aspiration. Pooling of secretions can lead to
aspiration. You need adequate O2 levels adm effective breathing. They may need to be intubated,
esp if they are unconscious to help maintain their airway. With suctioning, you have to be careful -
it can increase the ICP - it has to be done to keep the airway patent. Make sure you hyperventilate
b/4 you suction.
36. No narcotics or sedatives. Why? 1. They alter LOC (causes changes in our primary
indicator).
2. Decreases RR: Decreases oxygen, increases carbon dioxide = increased ICP. Drug of
choice is Codeine (Check allergy) – allows pt to be very arousable.
37. Good basic nursing care. Why? If pt wakes up they will not have pneumonia, skin
breakdown, contractures, etc. This is to prevent complications. For the client who is unconscious,
you are the one who will be protecting them, compensating for the protective reflexes, trying to
take care of their skin, joints and all of their other body functions, so that hopefully when they have
a recovery, they will be starting off on a better foot than if they had contractures, joint deformities,
pressure ulcers, skin breakdown.