Tca 1 (loc _ Icp)

1Altered LOC and ICP Kennedy

Altered LOC and Increased Intracranial Pressure - Result from underlying cause - Almost all problems result in these Altered Level of Consciousness - Symptom/result of an underlying condition, they are not primary things that happen. - MOST IMPORTANT indicator of a neuro client’s condition - is often one of the 1st things you start to see a change in -in the neuro client when they are having a change in neuro status or consciousness. Change in LOC is one of the first manifestations of many disease complications. Think about the diabetic. If they have hyper or hypoglycemia, you might see an altered LOC as a manifestation. With the elderly population, any type of infection can alter their LOC. All types of diagnoses can manifest as this big blanket term of altered LOC. - Gaged on a continuum (from fully conscious to comatose). On one end of the scale you have fully alert. On the other end you have comatose. Your client can fall anywhere on that continuum and can change depending upon their health status. - Fully alert - client is fully awake and fully oriented and has clear thought processes. They exhibit age appropriate behavior and respond appropriately. These are all required to be considered fully alert. o Respond to stimuli o Respond to questions 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. -

Begin to see Altered LOC o You begin to see altered LOC when your patient becomes disoriented, unable to follow commands or they need persistent stimuli to stay alert.

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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. Document what you observe - this is very important - even though these terms exist and they are used, and you do need to be familiar with them, they may mean something different from one person to the next or to 2 different individuals. Ex: stuporous to one person may be different from what you consider it to be. When documenting your assessment of your client - DOCUMENT WHAT YOU SEE. Ex: if they respond to light, tactile stimuli, or if they are drowsy but they awaken easily to voice, then write that rather than trying to remember which term is used to describe it. It is most important to document what you actually see. There is sometimes disagreement in what the terms mean so it is best just to document what you see. (For example, if you want to document arouses easily to verbal stimuli or required repeated verbal and tactile stimulation to arouse, then quickly falls asleep again. Just documenting what you actually see). Therefore, all staff that is reading your documentation/charting, will know exactly what the client’s baseline was when you got there. -

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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. -

Clinical Manifestations of Altered LOC: o Restlessness, anxious (will usually see this 1st) o Most commonly are going to see that slowing of verbal and motor response (this is what you usually think of - less responsive to stimulus, speech and ability to follow commands slows down) o Pupillary changes - depends on the cause. If you have a person who has been using controlled substances, you may see pupil changes when they begin to constrict. They will be smaller than normal. You may see a variation in the speed in which they constrict to light. You might also see the pupils begin to dilate. Pupil changes are common in altered LOC. What they do depends on the cause of the alteration in the LOC. Most often, if the cause is not found and treated, the client will start to move progressively down the continuum and will become progressively unresponsive to stimuli. For example, with a drug overdose – we would see constricted pupils. Dilated pupils can indicate increased intracranial pressure, or cerebral edema. o If cause is not found and treated will move down to where they are unresponsive – it is very important to identify the cause

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Assessment and Diagnostic Findings: o CT Scan (to try to determine the cause of alteration in LOC) – rules out major head traumas like hemorrhage, tumors or increased pressure on the brain o MRI (to try to determine the cause of alteration in LOC) o PET (to try to determine the cause of alteration in LOC) – this actually watches the brain as it functions. o EEG (to look at the electrical activity in the brain) o Laboratory tests (metabolic panels, CBC, lots of different labs to try to determine the cause of the alteration in the LOC) o Thorough physical assessment - very important. o GSC (Glascow Coma Scale) - used to measure LOC. (Pg 1917) • Measures eye opening, verbal and motor response to stimuli. Score ranges from 3 15. • 3 indicates a deep coma • 15 indicates that it is normal, fully alert client • 7 or less – considered to have severe brain damage • For children under 2 y/o it varies a little bit - read in Peds book about altered LOC and Increased ICP. • There are some special situations for infants and children.

Eye opening response:

Spontaneous To voice To pain None

4 3 2 1

Best verbal response

Oriented Confused Inappropriate words

5 4 3

Incomprehensible sounds 2 None 1 Best motor response

Obeys commands Localizes pain Withdraws Flexion Extension None

6 5 4 3 2 1

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. -

Complications: (Protect Airway is the number 1 priority) o Respiratory failure o Pneumonia o Pressure ulcers o Aspiration o All hazards of immobility – patients with LOC are very often going to be bedridden and immobile. *****make sure that the airway is maintained - may need the vent for airway - this is a priority - if they are unconscious or have a decrease in their LOC - make sure that their airway is protected - if they are unable to protect their own airway b/c they are completely unconscious or something then it becomes your responsibility. You must maintain their airway and prevent aspiration. They may need mechanical ventilation - especially if they are comatose. This puts them at RF pneumonia. *****pt is at RF all hazards of immobility. Pressure ulcers, DVT, pneumonia, deterioration of the MS system, all of these things you worry about in the pt with the altered LOC. *****They are at RF aspiration - even if the client is not completely comatose has a decreased ability to protect their own airway because of slowed responses. *****Certainly do not want to feed an unconscious client. Make sure that the client’s family knows not to feed this client. This is where patient and family education comes in. -

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. Nursing Assessment of Unconscious Patient: - LOC o Response to stimuli o GCS o Respiratory pattern - very important - you might see Cheyne-Stokes Respirations (periods of apnea, rapid respirations and then it will slow down to apnea, then you will start back to breath again and get real rapid and then slow back down and then have a period of apnea). This can suggest very deep damage within the hemisphere of the brain and the upper brainstem where the respiratory center is located. You might see hyperventilation - this may suggest a metabolic problem. Irregular respirations if you have damage involving the brain stem or medulla. Assess the respirations and the pattern of it and you also want to be sure that their respirations are adequate and you see this with ABGs and O2 sats. You must make sure that the respiratory pattern that they have is sufficient to maintain oxygenation. - Pupil size and reaction - look at whether they are symmetrical to light, if they are sluggish, if they are non-reactive, if they are abnormally dilated, or abnormally constricted. - Eye movements (doll’s eyes reflex) - will never be done until C-spine injury is R/O. This test will never be done on an alert client. If you have a client who has sustained a head injury, you assume that they also have a C-spine injury until it has been ruled out. Only done by a qualified MD - we would never do this test, but you will see it done in an unconscious client. The MD will turn the head rapidly to one side, and the response that you expect as a normal finding is that the eyes move together and to the opposite side of where it is being turned. This is call a positive (+) doll’s eye - this is a normal finding - you would want the eyes to be in conjugate movement - this is what it is called. They move together and away from the side that it is turned. If they remain fixed or move with the head or one eye moves and the other one doesn’t, this is abnormal and is a grave neuro sign because these are cranial nerves that are involved there. You are looking for brain stem involvement and cranial nerve involvement. - Oculovestibular response (caloric test) - not done if tympanic membrane is ruptured. This test will never be done on an alert client. Only done by a qualified MD - we would never do this test, but you will see it done in an unconscious client. The external ear canal is irrigated with ice water or iced saline. What you expect to see is that the eyes deviate toward the ear where the ice water was instilled. If you see no response or the eyes do not move together,

this is a bad neuro sign. You are looking for brain stem involvement and cranial nerve involvement. -

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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 Diagnoses: (that apply to alteration in LOC) pg 1852 in book - Ineffective airway clearance RT altered LOC - RF injury RT decreased LOC - FVD RT inability to take in fluids by mouth - Impaired oral mucous membranes RT mouth-breathing, absence of pharyngeal reflex, and altered fluid intake - RF impaired skin integrity RT immobility - Impaired tissue integrity of cornea RT diminished or absent corneal reflex - Ineffective thermoregulation RT damage to hypothalamic center - Impaired urinary elimination (incontinence or retention) RT impairment in neuro sensing and control - Bowel incontinence RT impairment in neuro sensing and control and also RT transitions in nutritional delivery methods - Disturbed sensory perception RT neuro impairment - Interrupted family processes RT health crisis 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.

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Protecting the patient: o Give them a safe environment o SR up X2, bed in low position o Avoid restraints if possible - will cause increased ICP if they resist against them and become agitated. If they are pulling on lines or tubes, you may just want to cover their hand rather than tying it down to the SR. Use the least restrictive means possible to try to achieve what you are trying to achieve. o Keep client calm and quiet - if you have a client who is comatose and has an altered LOC, and they don’t have increased ICP, it is OK to stimulate them. If you see that your client is not calm, and are becoming agitated or restless due to the stimulus of the environment around them, you need to try to change the environment and try to keep them calm and quiet. If they start to emerge from a coma, often times, you have to back off of the stimuli, because they are often restless and agitated. o Protect client’s dignity and privacy - be careful about what you are saying in front of the client. If you are going in to change the bed or give a bath, limit your conversation to appropriate topics. Don’t discuss their condition in front of them with the family - you don’t know how much they can hear. o Be an advocate for the client - be sure that they are being taken care of. As a nurse, you will spend the most time with the client. You will be responsible even thought here are other staff that are supposed to help turn and bathe and so those things - as a nurse you need to make sure that they are getting done. Make sure they are being turned, the mouth care is being done, skin care is being done and they are being kept clean and dry. The client is unable to do it for themselves.

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Maintain nutrition and hydration: o I&O, daily weightt o Slow IV fluid administration - especially if they have increased ICP - you have to control the amount of fluid that they receive. o NPO if unconscious

o Tube feeding or IV Fluid administration to compensate for if they are unconscious. -

Provide mouth care: o Check mucous membranes for dryness, inflammation, and crustations o Frequent oral care - apply some type of lubricant on their lips. If they are on O2, you would not use any oil-based product or Vaseline. Use water based only - to try to keep their lips moist. They need frequent oral care. o Rotate ET tube site - to prevent skin breakdown around their mouth.

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Maintain skin and joint integrity: o This is very important because the client who is unconscious is not going to be very sensitive to eternal stimuli (pressure or pain) from a joint or extremity being in the same place for a long period of time. o Frequent turning (q2h) – reduces pressure on the tissues and also helps the client to gain a position sense. o Specialty beds or heel pads - especially if they are beginning to get breakdown o Passive ROM - to prevent joint deformities o Good body alignment (natural body alignment position) - very important - you may have to use splints or put towel rolls in their palms. They may recommend putting tennis shoes on a client to prevent foot drop - at least for some periods during the day - keep them in shoes to maintain the proper alignment. o It is important that if they emerge from the unconscious state that they don’t have joint deformities that will prevent them from being mobile.

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Preserve corneal integrity: o Clean with NS o Artificial tears o Close eyes before applying patch - patches are used very cautiously - if patches are prescribed to be put over the eyes, make sure that the lids are closed - if not the patch may cause a corneal abrasion. It must be applied properly.

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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

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Preventing urinary retention:

o Assess for distention (overflow incontinence) - by palpating the bladder or using the bladder scanner. If client has overflow incontinence, it may appear that they are voiding, but the bladder is full and they are having overflow incontinence. Make sure that the bladder is emptying. o Indwelling catheter or intermittent catheter - if they have this - they will need catheter care. o If pt is voiding - keep dry and assess skin often -

Promoting bowel function: o Assess abdominal distention – measure the abdominal girth or by palpating to see if there is firmness in the abdomen, listen to their bowel sounds. o Monitor bowel pattern - you don’t want to have a patient who has been in the hospital for a month and then find out they haven’t had a BM in several days and it hasn’t been addressed - you will have a fecal impaction which is a lot more difficult to manage. o Check for impaction - if they have no BM or have a constant watery stool every time you turn them or every time they cough, you need to check them for an impaction. Any rectal stimulation is contraindicated for increased IPC - any rectal stimulation can increase the ICP. Be careful about doing this if the client has increased ICP. If the client is in a coma you would need to check them for an impaction. o Stool softeners, glycerin, suppositories and enemas - help promote their bowel function. Stool softeners are good as a preventive means - to try to prevent constipation and subsequent impaction. They are often given routine.

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Provide sensory stimulation: o Maintain day / night patterns - in the day time it is good to open the curtains and maybe turn on the TV or a radio or have the client’s family talk to them. May want to have the family record their voices and play the tapes during the day. At night turn the lights off to decrease the stimuli. o Touch and talk to client as if they can hear you - because often times they can. If they pt is unconscious, they can’t tell you if they can hear you or not. Talk to them and talk to others in the room as if they can hear you. Encourage family members to talk to them. If you have an infant or pediatric client, encourage the parents (as long as the client is stable) encourage them to cuddle and rock them, sing to them and other things that they would normally do. If you have family members that can’t be there a good bit of the time, you may want to use recordings of their voices or familiar sounds. We don’t do this with increased ICP because excessive stimulation further increases the intracranial pressure. This is talking about an unconscious client that is stable. o Orient to time and place every shift - tell them who you are, what day it is, that they are in the hospital - talk to them as if they can hear you. o Provide auditory stimulation (recordings, TV, radio) o May need to decrease stimulation when client is arousing from coma - to decrease restlessness and agitation (this is a nursing alert in the book). You want to really look at the way that the client is responding to the environment and try to adjust the environment to them. If they seem like they are agitated and restless, then back of with the stimulus for a little bit and see if it helps. o Best indicator of needing to change their environment is to look at pt - see how they are responding to the environment. If they seem to be restless and agitated, then you need to change something.

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Meeting family needs: o Don’t forget about the family. Often times when a patient is comatose has become that way very rapidly as the result of a head injury, or an automobile accident or some

unforeseen illness. So the family is coping with a lot. They may have to make the adjustment very suddenly. o When talking to the family you need to: • Give accurate info - don’t give them false hope - be truthful, but as optimistic as you can. Clarify information about the client’s condition. If you know how to clarify the info, then do so - if you don’t find someone who can clarify it and give them the correct information about the client’s condition. • Provide emotional support - in decision making. Families often have to decide about long term care options, organ donations if the client is brain dead. Support them in whatever decisions they make. These are not easy decisions to make and they are very individualized. As a nurse, your role is not just to provide support to the patient, but also the patient’s family. • Refer to support groups - if it would be beneficial to them. There may be some community resources out there that they can benefit from. -

Monitor and manage potential complications: o Respiratory failure • We can detect monitor respiratory status and detect early changes by monitoring ABGs, O2 sats, respiratory pattern, breath sounds, etc. o Pneumonia (elevated WBC, temp, characteristics of their sputum, lung sounds, cough) o Aspiration - try to detect it early - prevention is the best thing to do. Look for coughing or abnormal lung sounds. o Impaired skin integrity (prevention is key) - clean, dry, and turn. If they do start to get breakdown - it need to be treated very aggressively. You would need a wound care consult. o DVT - anti-embolism hose for the client who is unconscious and in bed. Passive ROM exercises will help. If it is not contraindicated, they may be on a low-dose anticoagulant like Lovenox - if they are not having hemorrhage. If they are unconscious, you will not be able to assess a Homan sign - they will be unable to tell you if it hurts when you flex their foot. You have to look for other s/s - look at their extremities, you may even have to measure them to detect changes in the size. Check for asymmetry or redness, warmth on the extremities.

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Depending on cause of the altered LOC: o Assess for seizure and increased ICP. If the brain tissue is irritated, the client will be more prone to have seizures. Often times, your unconscious client has increased ICP and altered LOC with head injury or trauma. o Administer appropriate meds - will talk more about when you get into specific disorders. (may include: for infection - ABX, for increased ICP steroids or osmotic diuretics and anti-convulsants)

INCREASED INTRACRANIAL PRESSURE 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%

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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. Patho: of increased ICP o Relationship between IC volume and pressure is altered o Most commonly results from head trauma, but can also occur from space occupying lesions like a tumor in the cranial vault, hemorrhage or infection - any of these can lead to increased ICP. o Whatever the cause – increased ICP left untreated - Results in: • Decreased cerebral blood flow (due to compression of the blood vessels in the brain). Then you have ischemia and a rising CO2 level. This stimulates the vasomotor center. Your body senses that when those blood vessels are constricted, and you are not getting enough blood flow to the brain and you have increased CO2 your body senses that it needs more O2. What do the blood vessels do? Vasodilates and brings more blood up to the brain. Your heart rate is going to slow down - you will have a slow, bounding pulse - it is trying to have an effective heart beat to try and get the blood pushed up to the brain so that oxygenation is maintained. You have something that is taking up more room than it is suppose to and the blood vessels in the brain become suppressed and you have decreased blood flow. • Cerebral edema - from fluid accumulating in the intracellular and extracellular spaces. This increases the brain tissue volume. One way that your body tries to compensate for cerebral swelling or increased volume is by decreasing production of

CSF or displacing CSF. This is the easiest way that your body can compensate to changes in ICP. It tries to move the CSF elsewhere. If this is ineffective, then: • Shifting of brain tissue, brain stem, and herniation can result, form increased pressure. Your intracranial contents get to the point where the pressure is so great that the tissue has no where else to go except downwards or to the side. If you have a hemorrhage on one side and it is occupying a lot of space, then eventually the brain tissue is going to start shifting and start compressing on itself. • Herniation (of the brain). Without intervention, shifting of the brain tissue and herniation will result. • May compensate by moving CSF -

Cerebral response to ICP: o Cerebral vessels dilate and they constrict to try to maintain a constant cerebral blood flow. o This is the way the body attempts to maintain the cerebral blood flow in the presence of increased ICP. Two ways (listed below) that the blood vessels respond to try to maintain an adequate cerebral perfusion pressure (CPP) - this is a term that you need to be familiar with. CPP is the amt of blood flow that is needed to provide the brain with adequate oxygenation and glucose and nutrients that is needed. It is the difference between the Mean Arterial Pressure (MAP) and ICP. o The body has a couple of autoregulation mechanisms that it tries to maintain cerebral blood flow and CPP with: 1- Pressure autoregulation: o Under normal circumstances, cerebral perfusion pressure (CPP) is maintained regardless of Systemic Blood Pressure within normal limits. But normally regardless of increases or decreases in your blood pressure, your CPP is going to be maintained at a constant level by the body changing the size of the blood vessels to the brain - they will either vasoconstrict or vasodilate. This will maintain the constant CPP. If the BP increases - the cerebral vessels constrict to try to maintain the constant pressure and try to prevent the increased pressure from getting to the brain (contrict to cut down some of the blood flow which limits the pressure). If your BP falls, the cerebral vessels will dilate to try to get more blood to the brain. This is normal autoregulation. no matter what your BP is (within limits) your body maintains a constant CPP - thru vasodilation and vasoconstriction. o If your ICP gets way too high or your BP gets way too high, your body is going to fail to do this. It can only do this to a certain point. o MAP must be 50 - 60 mmHg higher than ICP in order to maintain an adequate CPP 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. -

To calculate CPP, this formula is used:

o CPP=MAP - ICP (so 1st you have to calculate the Mean Arterial Pressure) this is done by taking the Systolic Blood Pressure - the Diastolic Blood Pressure / 3, then add the DBP back and you get the MAP. Then you subtract the ICP. So in order to calculate this, you must have the BP and the ICP. o S-D/3, +D = MAP. Then MAP - ICP = CPP o normal Cerebral Perfusion Pressure = 70 - 100 o Irreversible neuro damage occurs when CPP decreases below 50. o Anything below 70 is inadequate. For adequate perfusion of the cerebral tissue the CPP needs to be 70 – 100. EX: BP - 100/60 ICP: 25 Calculate the CPP: 100 – 60 = 40 40 / 3 = 13.3 13.3 + 60 = 73.3 73.3 - 25 = 48.3 Is the CPP within an acceptable range? NO What do you do? Call MD - this is bad -

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

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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.

Cerebral Blood Flow Increased ICP

Cerebral Hypoxia (O2) DECOMPENSATION CYCLE “killing itself off”  CO2;  PO2;  PH Acidosis

Cerebral Edema

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) -

Clinical manifestations:(for increasing ICP) o Altered LOC - !st sign. Altered LOC is the 1st sign with many neuro problems and it is no different with ICP. Most likely you will see the slowing of speech, not following commands well - but you will also see the other end of the spectrum - restlessness, agitation - they don’t feel right, they don’t feel good and they begin to become disoriented and confused and agitated. Any change in the LOC is significant. It is normally one of the 1st signs. o Motor and sensory loss - may have weakness or paralysis on one side - if they have compression of one side of the brain from the increasing pressure. Immediately, you will see the total body flaccidity. For example if they have a tumor or hemorrhage on one side of the brain, you might see hemipalygia at first. If you have pressure on the left side of the brain, the motor deficits will be on the right side of the body. o Headache - usually this HA is characterized as a worsening HA, increasing in intensity - it is aggravated by any kind of movement or straining. The brain itself is insensitive to pain, but all of the blood vessels that are being compressed and stretched is what causes this worsening. o Pupillary changes (pressure on optic nerve) - this is very serious. If you begin to see pupillary change where they begin to dilate, and become sluggish, then you know that you have some pressure on vital centers. The cranial nerve (Cranial Nerve 3) comes out from the brain stem and around the tentorium. So if you are seeing pupillary dilation due to increased ICP - this is a very serious sign. At 1st you will see that they begin to just progressively dilate and they may still be sluggish. But if you have a fixed and dilated pupil, this is a very grave sign of impending brain stem herniation o Papilledema - swelling of the optic disk. How would that be assessed? Usually an MD would assess this with an ophthalmoscope and would look into the pupils to see the optic disc. You may hear it referred to as a bulging disc or a choked disc. It is a bulging of the optic disc. That has to be seen at the back of the eye with an ophthalmoscope. It is not something that you will go in and see. They may complain of visual changes, blurred vision. o Vomiting (projectile often times without nausea 1st). It is due to pressure on the medulla - on the vomiting center. It is projectile and often times - no nausea precedes it. o Alterations in Vital Signs:

• Cushing’s response (Cushing’s reflex) - initially you might see this: (these are signs of increasing ICP)  Elevated systolic blood pressure  Widened pulse pressure (which means the diastolic remains unchanged)  Decreased HR (slow, bounding pulse) • Altered respirations (may see and irregular pattern) at the very end before death, with Cushing’s Triad, you will see bradypnea, you might get what is referred to as agonal respirations (very irregular). You can see all kinds of breathing patterns with increased ICP depending upon where the pressure is on the brain. You can even see hyperventilation before the bradypnea starts. So it is important to assess the respiratory pattern. Most typically, when you have increasing ICP, you will see the decreased respirations rate or the ataxic respiratory rate, most definitely the elevated SBP and widened pulse pressure, and the slow, bounding pulse. These are all characteristics of increasing ICP. • Elevated temp - this is due to pressure on the brain stem. A very high, uncontrollable temp will occur with increased ICP. • Cushing’s triad (indicates decompensation) - bradycardia, HTN, bradypnea o Loss of brain stem reflexes (if no intervention or intervention is not possible in the client with increased ICP) - these are controlled by cranial nerves: • the pupil - you will lose the ability of the cranial nerve to constrict and dilate the pupil and you will have what is called a “blown pupil” - it will be fixed and dilated. It may be on one side or both sides. • Corneal reflex, gag reflex, swallow reflex - all of those are brain stem reflexes. • In the presence of ICP, when a person begins to lose these reflexes – death could be imminent in this client. o Might see some of the other things that we talked about in the assessment of an unconscious client such as: • Posturing • Just prior to this we might see total body faccidity. -

Life span considerations: o Elderly, infants and children do better with changes in ICP. o Elderly may have increased ICP with delayed signs and symptoms due to cerebral atrophy (decrease in brain mass). There is an amount of atrophy of cerebral tissue that is normal in the elderly. They can lose from 5 and up to 17% of their brain mass thru the normal aging process. So they have a little more room in the intracranial vault to accommodate the increased ICP. This why you may see a client who is 90 y/o come in and have a huge sub-dural hematoma - if it had been a younger client, there would have been less space available in the intracranial vault and symptoms would have been occurring a lot sooner. The elderly have more room for these changes because of brain atrophy and therefore have a little bit more room for compensation. o Infants and children (infants especially) may have increased ICP with delayed S/S due to open fontanels and the sutures are not completely fused. • sutures may re-open and separate up to 10 y/o in the presence of increased ICP this is not common, by any means, but it can happen. • So infants and young children, especially can compensate a little bit from increased ICP b/c their skull is flexible - we as adults don’t have that luxury - our skull is rigid and fixed and the sutures are fused, so there is no where for the pressure to go.

• In infants the posterior fontanel fuses at 6 to 8 weeks. The anterior fontanel fuses between 12 and 18 months. So until then, infants will have a little bit more room for compensation. Increased ICP in infants: - Clinical manifestations (that do differ a little bit from adults): o Tense, bulging fontanels o Cranial sutures can begin to separate o Macewen (cracked pot) sign (when the sutures do separate and you have all of the bony plates kind of moving around up under the scalp) - it is almost like a piece of broken asphalt road - all of the little boney plates are kind of displaced and separated o Irritable (very) o High pitched cry (very common in an infant with increasing ICP) o Increased head circumference (this is why an infant’s head circumference is measured so often when they are 1st born - this is to look for abnormal head growth, or rapid head growth to try to look for increased ICP. What is one of the most common causes for increased ICP in an infant - other than trauma? Hydrocephaly o Distended scalp veins o Changes in feeding habits (maybe they won’t suck or won’t feed) o Crying when held or rocked (you would see this because the movement is irritating to them - just like in an adult - any change in position or movement at all causes headache and pain. You will see this in infants where they will be very irritable when you pick them up to rock them and hold them o “Setting sun” sign - this is where the eyes deviate downward (the actual iris and pupil deviate down towards the cheek with increased ICP) Increased ICP in children: - Clinical manifestations: o HA o Nausea o Vomiting (often without nausea - same as for an adult) o Diplopia (double vision) and blurred vision o Seizures o Personality and behavioral changes - irritable, restless, drowsy, developing a lack of interest in activities, declining in school performance, increasing complaints of being tired or having a HA, needing to sleep more often, changes in LOC, they can have memory loss, they can progress down the continuum of LOC if the ICP gets high enough. They will go down the same course as an adult - they can have the decreased motor responses, eventually lose consciousness and have the same symptoms as an adult. o Vital sign changes • Cushing’s response (Cushing’s reflex) - initially you might see this: (these are signs of increasing ICP)  Elevated systolic blood pressure  Widened pulse pressure (which means the diastolic remains unchanged)  Decreased HR (slow, bounding pulse) • Respirations get very abnormal and irregular -

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.

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Complications or collaborative problems of increased ICP: o Brain stem herniation o Diabetes insipidus (results from decreased ADH) – this is a dysfunction of the hypothalamus within the brain o SIADH - syndrome of inappropriate ADH (anti-diuretic hormone) - too much ADH – this is also a dysfunction of the hypothalamus within the brain o Cessation of cerebral blood flow (from compression of the vessels - which leads to tissue death). It is a complete stop in blood flow

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. -

Diabetes insipidus - a complication of increased ICP: o Results from decreased secretion of ADH. o To try to keep these separated, think of what ADH is - anti-diuretic hormone. So if you have a lot of it, you won’t be able to urinate - b/c you will have lots of anti-diuretics in your body. o Diabetes insipidus is a decrease in ADH - so you don’t have enough of the ADH you don’t have enough of the hormone to prevent you from urinating. So it will mimic diabetes - polyuria. - an increased urine output. o Clinical manifestation: • excessive Urine Output (>200 ml/ hr for 2 hrs) - you need to start suspecting this condition. • hyperosmolarity - you have an increased amount of Na+ in the blood in the intravascular spaces. This is b/c you have decreased fluid volume. You are diuresing and have lots of UO. This increases the Na+. • The specific gravity of the urine will be decreased because there is so much fluid there. The serum Na+ is going to be elevated because there is so much fluid being lost (urine output) makes the blood more concentrated (hypernatremia). o Treatment: • Fluid Volume replacement (you might increase the fluid rate to match the rate of diuresis. So typically what you would do is FV replacement) • This client will need to have a Foley catheter. • They need to be on frequent output checks (at least hourly) • Electrolyte replacement (if needed) – they have an increase in the osmotic particle in their blood (Na, glucose, BUN) so you might see other electrolyte imbalances. • Decompression (Vasopressin, DDAVP) therapy - synthetic ADH – to slow down urine output. Can be given by injection or nasally.

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SIADH: (opposite of diabetes insipidus) o Results from increased secretion of ADH. Controlled in the brain thru the hypothalamus. It is the increased pressure that causes this dysfunction to occur. o Clinical manifestations: • decreased Urine Output

• hyponatremia (low serum Na+ because you have the extra fluid circulating in the blood) • Fluid Volume Overload can result • The specific gravity of the urine will be increase. • The serum Na+ is decreased o Treatment: (often times the SIADH is self-limiting in a person with increased ICP) • fluid restriction (will see done most of the time and it will be the 1st thing they do & usually it is self-correcting) • 3% hypertonic saline solution (to help replace the Na+) • If chronic SIADH: Lithium, Demeclocycline. • Lithium is used in bi-polar disorder and is a mood stabilizer. It is also being found to decrease the renal tubular response to ADH. It acts on the kidneys to keep them from being as responsive to the extra ADH - it serves as a diuretic. The Demeclocycline (a tetracycline antibiotic) does the same thing. Both of these drugs tend to have a diuretic effect on a client with this condition. • The 1st thing you will do is to restrict fluids and it is usually self-correcting. 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. Management of Increased ICP: - Treat as an emergency (because the potential complications are life threatening brain stem herniation, compression of the blood vessels - those complications are life-threatening - so you TREAT IT AS AN EMERGENCY). If you have a client with increased ICP, especially if it occurred acutely (from a head injury or a hemorrhagic stroke or a tumor that is causing increased ICP) you will see this client in the ICU until the ICP is better controlled. They will be in a critical care setting. - Monitor ICP o ventriculostomy (common way to monitor ICP). This is where a fine-bore catheter is inserted into the ventricles of the brain (usually put into the non-dominant hemisphere of the brain – for most people this would be the right hemisphere of the brain). It measures the pressure of CSF that might increase ICP. The advantage of the ventriculostomy is that when you are in the ventricles, you can measure the pressure, you can instill medications directly into that space (such as if you have an infection there you could instill antibiotics), you can sample CSF and send it down for analysis. So when you are in the ventricles, you have all of these advantages. What is one huge disadvantage? You have a huge risk for infection. You must maintain strict sterility (with any of these, but especially with the ventriculostomy). Another complication is collapse of the ventricles – if you drain fluid too rapidly. The catheter may also become occluded where it won’t drain. This can be used not only to measure ICP, but also to drain CSF out. It can be set not only to an ICP monitor (electronic device), but it can be set on a gravity drainage system. The neurosurgeon will give specific orders on what the pressure needs to be set at on the drainage device. There is usually a level to level it usually right above the ear. In the case of gravity drainage system, the nurse needs to be very cautious of the patient’s positioning. For example if the HOB is elevated above where the drain is, then the CSF will be dumped out quickly and this could cause ventricular collapse. The same is true if the patient were somehow lowered below the level of the device, but the drain will not be draining like it is suppose to and the patient will have increased ICP. The nurse needs to post signs everywhere and make anyone coming in contract with this patient about positioning. If the patient needs to be moved, the nurse needs to clamp the tube briefly until it can be adjusted to the level right above the ear.

o sub-arachnoid bolt (or screw) - it is put into the sub-arachnoid space under the skull it doesn’t require puncture the ventricles (advantage). It is not quite as accurate as the ventriculostomy is - accuracy can be decreased if the screw becomes blocked by a clot or by brain tissue. o epidural monitor (has a low incidence of infection and complications and appears to read pressure accurately) - it doesn’t get into the ventricles - you are not allowed to sample the CSF like you are with a ventriculostomy - this is a disadvantage. o fiberoptic monitor - this is one of the newer thing that is used. It is a transducer tipped catheter that can be inserted into the ventricles, in the sub-arachnoid space, and several areas of the brain. You have a pressure sensor. o The ventriculostomy and the fiber optic and even the other 2 can be hooked to a transducer that actually measures the pressure. The book goes into all these ways on the ICP monitor and you don’t have to know anything about that. But this will be done in a critical care setting. o the only thing you may see out on the floor is the a ventriculostomy drain -it is a ventriculostomy but it is not hooked to a pressure sensor. It is a gravity flow system and it is set at a certain pressure level. You may see this out on the floor with a pt who has got some mild ICP. It helps to drain excess CSF off to help regulate the pressure. -

Decreasing Cerebral Edema o osmotic diuretics (mannitol) – pulls fluid from the intracellular and the intravascular spaces - it helps to kind of dehydrate the brain tissue. What do you expect to happen with an osmotic diuretic in a normal individual who has increased ICP? It is going to pull that fluid from the brain tissue into the intravascular space. What normally occurs when you have increased volume in your vascular space? You will have diuresis. Your kidneys will hopefully pick up on that and you will have an increase in Urine Ouput as a result of Mannitol administration. Sometimes that does not occur, your kidneys are not pulling off as much fluid as they need to and so sometimes you have to give loop diuretics (Lasix) to get it out of your intravascular space. What we expect; and we need to monitor UO when you get a client who is on Mannitol to make sure that they are diuresing. If they are not diuresing adequately, and they are showing signs of fluid volume overload then you may need to increase diuresis thru the use of a loop diuretic. o Corticosteroids (Dexamethasone, Decadron) - decrease inflammation. It helps decrease cerebral edema by decreasing inflammation. Try to give the cranial vault a little bit more room by not having the brain tissue as edematous and swollen. o Fluid restriction - this is to decrease the circulating fluid volume. Keeping these clients slightly dehydrated if they have increased ICP - this is usually what you will see fluid restriction, diuretic administration, keeping them slightly dehydrated so that you don’t have swelling of the brain tissue or have an excess of intravascular volume circulating there and putting even more fluid into the cranial vault. We want to keep the brain tissue dehydrated. o Hypothermia has been used, but it is not a mainstay of treatment. This decreases the metabolic demand on the brain. We certainly do not want them to have hyperthermia because this increases the metabolic demands on the brain. This is not routinely done.

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Maintaining Cerebral Perfusion: o Improve CPP by improving Cardiac Output (fluid volume, inotropic agents Dopamine) - may need to increase fluid volume if they are hypovolemic or hypotensive. Inotropic agents - Dopamine - you might give this if they have a low BP. This is carefully done, you don’t to overstress the body or have the BP too high. This may improve the CO.

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Decrease CSF and Intracranial Blood Volume o Cautious CSF drainage (may use a ventriculostomy drain). It has to be done slowly to prevent rapid changes in the pressure and subsequent herniation. o Hyperventilation - helps with intracranial blood volume by increasing the circulating O2 so that you have vasoconstriction of the cerebral vessels. Vasonstriciton will limit the amount of fluids that are getting to the brain. Lately this has been a little controversial because of the increased CO2 they think is causing problems, but you might see hyperventilation used in the client with increased ICP.

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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)

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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.

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Decrease Metabolic Demands: o This patient might be put on a ventilator, chemically paralyzed and put in a drug induced coma in order to rest their body and decrease the metabolic demands on the body while they have increased ICP. o high dose barbiturates (drug induced coma) o pharmacologic paralytic agents o requires constant monitoring o With the person with acute increased ICP, you might see them on high dose barbiturates and paralyzing agents. This is a client who has to be intubated and on mechanical ventilation. They must be in critical care to do this. Normally on the floor, if you have a person who is having increased ICP, you do NOT want to give them sedatives or barbiturates b/c it alters the LOC, if you give them opioids (morphine) it decreases their respiratory rate and we don’t want to do that with the pt with increased ICP. So if they are getting high dose barbiturates they are in a critical care setting where they are mechanically ventilated and intubated. o If they are on these, they need constant VS monitoring, EKG (cardiac) monitoring, ICP monitoring - all of the external things that we would look at to monitor neuro status. When you put them into a drug induced coma, you can not assess neuro status the way you normally would.

- 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

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CP / potential complication: o Brain stem herniation o Diabetes insipidus o SIADH

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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. 5. Hyperventilation. Why? Maintain adequate oxygenation during suctioning increase oxygen, decrease carbon dioxide (potent vasoconstrictor). Makes the vessels constrict to prevent increased ICP, it decreases your CO2 level. 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.