/
Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)

Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)

Watch More! Unlock the full videos with a FREE trial
START FREE TRIAL
Master
To Master a topic you must score > 80% on the lesson quiz.
Take Quiz

Included In This Lesson

Study Tools
Outline
Transcript
Additional Lessons

Study Tools For Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)

Increased Intracranial Pressure (ICP) Interventions (Picmonic)
Increased Intracranial Pressure (ICP) Assessment (Picmonic)

Outline

Overview of Nursing Care Plan for Increased Intracranial Pressure (ICP)

Think of your skull as a box that holds your brain, blood, and spinal fluid. There’s only so much room in this box. Increased Intracranial Pressure (ICP) happens when there’s too much pressure inside this ‘box.’

 

This can happen for a few reasons:

 

  1. Too much fluid: Sometimes, your body makes too much spinal fluid (the fluid that cushions your brain), or it doesn’t drain properly. It’s like having too much water in a water balloon – it starts to stretch and put pressure on the brain.
  2. Swelling: If your brain gets swollen, maybe because of an injury or illness, it can take up more space inside your skull. It’s like when you sprain your ankle, and it swells up, but in your skull, there’s no extra room for swelling.
  3. Blood: If there’s bleeding inside the skull, like from a head injury, that extra blood can increase the pressure.

 

Increased ICP is serious because it can prevent blood from flowing properly to your brain, which causes brain damage if it’s not treated.

 

Symptoms might include a severe headache, nausea, vomiting, drowsiness, and problems with vision. In severe cases, it could lead to unconsciousness.

Pathophysiology of Increased Intracranial Pressure (ICP)

 

    • What is Increased Intracranial Pressure (ICP)?
        • It’s when there’s too much pressure inside your skull. Think of it like too much air in a balloon, pressing on everything inside.
    • Why Does it Happen?
        • It can be caused by things like head injuries, brain tumors, swelling of the brain (cerebral edema), or bleeding inside the head.
        • Inside your skull, there’s your brain, blood, and a special fluid called cerebrospinal fluid. If there’s too much of any of these, the pressure goes up.
    • What Does the Brain Do to Handle Extra Pressure?
        • Your brain tries to fix this by moving some of the cerebrospinal fluid to your spinal canal, or by adjusting the amount of blood inside your skull.
        • But sometimes, these fixes aren’t enough, and the pressure keeps rising.
    • Why is High ICP a Problem?
        • If the pressure gets too high, it can stop blood from flowing properly to your brain or squeeze parts of your brain, which can cause those parts of the brain to stop working properly or even die from lack of perfusion.
    • What Do Nurses Need to Do?
      • It’s important for nurses to understand all this to help patients with high ICP.
      • They need to know the right ways to lower the pressure, like giving certain medicines or other treatments, to keep the brain safe.

Etiology

 

    • What Causes Increased ICP?
        • It’s caused by different things that make pressure go up inside your skull.
    • Head Injuries:
        • Things like concussions or serious head injuries can cause swelling and bleeding in the brain, which increases pressure.
    • Bleeding Inside the Skull:
        • If blood vessels in the brain burst (like from an aneurysm), the leaked blood can raise the pressure.
    • Brain Tumors:
        • Tumors can grow in or near the brain, taking up space and pushing against brain tissue. This can block fluid flow and increase pressure.
    • Infections:
        • Brain infections like meningitis or encephalitis can make the brain swell, leading to higher pressure.
    • Too Much Fluid:
        • Hydrocephalus is when there’s too much cerebrospinal fluid in the brain. This extra fluid can cause pressure to build up.
    • Why Nurses Need to Know This:
      • Understanding these causes helps nurses figure out the best way to help. Each cause might need a different type of care to reduce pressure and prevent more brain problems.

Desired Outcome

 

  • Main Goal:
    • To maintain normal ICP (7 – 15 mmHg) and keep the brain healthy.
  • Key Objectives:
    • Keep ICP in Check: Make sure the pressure inside the skull stays at a safe level (7 – 15 mmHg).
    • Ensure Adequate Cerebral Perfusion: The brain needs enough blood flow to work right, so it’s important to monitor this.
    • Avoid Complications from Increased ICP: Prevent issues like brain herniation, where parts of the brain get pushed into places they shouldn’t be.
  • Monitoring and Detection:
    • Watch for changes in how the patient’s brain is working, like if they become less conscious or their vital signs change.
    • Be quick to react if these signs show the pressure might be going up.
  • Treatment and Teamwork:
    • Adjust treatments as needed, based on careful monitoring.
    • Work closely with doctors and other healthcare professionals to make the best decisions for the patient.
  • Overall Aim:
    • To keep the patient’s brain functioning well and improve their overall health and well-being.

 

Increased Intracranial Pressure (ICP) Nursing Care Plan

Subjective Data:

  • Confusion
  • Memory Loss

Objective Data:

  • Altered LOC
  • Pupil changes
  • Babinski Reflex
  • Posturing
  • Seizures
  • Cushing’s Triad (impending herniation)
    • Abnormal Resps
    • Wide pulse pressure
    • Bradycardia
  • Elevated Temp

Assessment for Increased Intracranial Pressure (ICP)

 

  • Neurological Assessment:
    • Conduct a thorough neurological assessment, including assessments of consciousness, level of alertness, pupillary response, and motor function. Monitor for any signs of neurological deterioration, such as changes in responsiveness or focal deficits.
  • Vital Signs Monitoring:
    • Continuously monitor vital signs, including blood pressure, heart rate, and respiratory rate, to detect any deviations that may indicate changes in intracranial pressure. Pay close attention to alterations in respiratory patterns, as irregularities may affect ICP.
  • Pupillary Assessment:
    • Assess pupil size, symmetry, and reactivity to light. Anisocoria (difference in pupil size between left and right)  or sluggish pupil response may indicate neurological compromise and increased ICP.
  • Glasgow Coma Scale (GCS):
    • Utilize the Glasgow Coma Scale to quantify the level of consciousness. Frequent GCS assessments help track changes in neurological status and guide interventions.
  • Cerebrospinal Fluid (CSF) Drainage:
    • If applicable, monitor cerebrospinal fluid drainage systems for intracranial pressure control. Evaluate the clarity, color, and volume of drained fluid, and assess the insertion site for signs of infection or malfunction.
  • Headache Assessment:
    • Assess the presence, intensity, and characteristics of headaches, as they can be indicative of increased intracranial pressure. Document any changes in headache patterns or associated symptoms.
  • Respiratory Assessment:
    • Evaluate respiratory status, emphasizing the assessment of oxygen saturation, respiratory rate, and the presence of abnormal breathing patterns. Respiratory distress may exacerbate increased ICP.
  • Diagnostic Imaging:
    • Review diagnostic imaging studies, such as CT scans or MRIs, to identify the underlying cause of increased intracranial pressure, such as tumors, hemorrhages, or edema.
  • Fluid and Electrolyte Balance:
    • Monitor fluid and electrolyte balance closely, as imbalances can contribute to cerebral edema. Assess serum sodium levels, and aim for euvolemic fluid status to prevent fluctuations in intracranial pressure.
  • Pain Assessment:
    • Evaluate the patient’s pain levels and response to pain management interventions. Effective pain control can contribute to overall comfort and may indirectly impact intracranial pressure.
  • Collaboration with Monitoring Devices:
    • Collaborate with the use of intracranial pressure monitoring devices, if applicable, to directly measure and manage intracranial pressure. Ensure proper functioning and interpretation of device readings.

Nursing Interventions for Increased ICP

 

  • Frequent neuro checks (q1h)

Neurological changes related to increasing ICP may be subtle or may occur rapidly. Frequent detailed neuro checks allow changes to be recognized quickly so that interventions can be initiated.

 

  • Monitor Temperature and hemodynamics, including MAP and CPP

 

  • With a loss of autonomic regulation, a patient’s temperature could become very elevated (104°+).
  • Monitor hemodynamics to assess for Cushing’s Triad and to evaluate Cerebral Perfusion Pressure (MAP – ICP).

 

  • Avoid sedatives or CNS depressants if possible

 

These medications could alter neuro checks, so avoid them whenever possible to get an accurate neuro exam.

 

  • Administer ordered medications:
  • Osmotic Diuretics (Mannitol) – decrease edema
  • Hypertonic Saline (3% saline) – decrease edema
  • Corticosteroids – decrease inflammation

 

These medications help to decrease the circulating CSF volume as well as to decrease any cerebral edema. This intervention decreases the pressure within the cranial cavity based on the Monro-Kellie Hypothesis.

 

  • Prepare patient for surgical intervention
    • Craniectomy
    • External Ventricular Drain

 

A craniectomy is used to remove a portion of the skull (bone flap) in order to allow space for cerebral swelling.

External Ventricular Drain (EVD) is a catheter placed into the ventricle to drain blood or CSF in the event of an elevated ICP.

 

  • Level and Zero EVD to tragus (external auditory meatus of the ear). Maintain open per orders (i.e. open at 10 cm H2O)

 

EVD should be leveled to the tragus to be approximately in line with the 4th ventricle in the brain. 10 cm H2O correlates to approximately 7-8 mmHg ICP – therefore any increase in the ICP above 7-8 would cause CSF to drain. If the EVD is not leveled appropriately, too much or too little CSF could drain. Too little drainage could cause increased ICP and possible brain herniation.

 

  • Monitor Electrolytes and Urine Output

 

If the patient is on mannitol or hypertonic saline, this could cause fluctuations in sodium levels, which could lead to seizures. Close monitoring in an intensive care unit is typically required for administration of these medications.

 

Urine output should be monitored to ensure diuresis with mannitol, but also to monitor for the possible development of diabetes insipidus.

 

  • Patient positioning interventions to minimize ICP:
    • Maintain HOB 30-45°
    • Decrease stimuli
    • Avoid valsalva maneuvers

     

    Maintain HOB 30-45°

    • HOB < 30 = increased blood flow to brain → Increased ICP
    • HOB > 45 = increased intrathoracic pressure → decreased venous outflow from brain → increased ICP

    Decrease stimuli

    Agitation or stress can cause increased ICP

    Avoid valsalva maneuvers

    Coughing or bearing down can cause increased ICP

 

Evaluation for Interventions for Increased Intracranial Pressure (ICP)

 

    • What’s the Focus?
        • To check if the treatments for high ICP are working and helping the patient’s brain health.
    • Regular Brain Checks:
        • Neurological Checks: Regularly check the patient’s consciousness, eye responses, and muscle movements.
        • Monitor Vital Signs: Keep an eye on temperature and blood pressure to make sure they’re in the safe range.
        • Monitor ICP, if monitoring device is in place.
        • Medication Monitoring: Make sure the patient is getting and responding well to their medicines by assessing their neurological status, fluid balance and related lab results.
    • Surgical Intervention Check:
        • If there’s surgery like a craniectomy (removing part of the skull) or placing an external ventricular drain, check how well these are working by checking surgical site and monitoring any ICP readings .Other Important Tests:
        • Look at things like electrolyte levels and how much the patient is peeing to understand the brain’s blood flow and fluid balance.
    • Teamwork and Communication:
        • Work closely with the entire healthcare team and keep communicating about the patient’s progress.
        • Use this information to make any needed changes to the care plan.
    • Goal:
      • To ensure the patient’s ICP is in the normal range and the patient does not experience neurological complications.

References

View the FULL Outline

When you start a FREE trial you gain access to the full outline as well as:

  • SIMCLEX (NCLEX Simulator)
  • 6,500+ Practice NCLEX Questions
  • 2,000+ HD Videos
  • 300+ Nursing Cheatsheets
Start Free Trial

Transcript

In this lesson today, we’re going to take a look at the care plan for increased intracranial pressure, also known as ICP. In this lesson, we will briefly take a look at the pathophysiology and etiology of increased ICP. We’re also going to take a look at additional things that would be included in an ICP care plan, like subjective and objective data that your patient may present with as well as the necessary nursing interventions and rationales. 

 

Increased ICP is defined by an increase in pressure in the skull caused by an increase in the volume of brain tissue, blood, cerebrospinal fluid, or by the presence of a space occupying lesion. The increased pressure compresses brain tissue, which causes damage to the neurons leading to neuron changes, eventual herniation and brain death. Causes include cerebral edema, hemorrhage, hydrocephalus, hypertension, cerebral visa, dilation, a tumor, or a mass.

 

The desired outcome is to minimize ICP, to prevent any damage to nerve tissue and prevent long-term neurological deficits. Okay, so let’s take a look at some of the subjective and objective data that your patient with increased ICP may present with. Remember, subjective data are going to be things that are based on your patient’s opinions or feelings. These things might include confusion or memory loss. 

 

Objective data includes altered level of consciousness, pupil changes, but Babinski reflex, posturing, seizures, Cushing’s triad, which indicates impending herniation and includes abnormal respirations, a wide pulse pressure and bradycardia. We will also see an elevated temperature in these patients.  

 

Okay, so let’s jump into some of the nursing interventions for increased ICP. Complete neuro checks every hour as neurological changes related to increased ICP may be subtle or rapid, so  Frequent detailed neuro checks allow changes to be recognized quickly. Interventions can be initiated in elevated temperatures, sometimes as high as 104 is common with increased ICP because of the loss of autonomic regulation. Be sure to monitor your patient’s temperature, also monitoring hemodynamics to assess for Cushing’s triad and to evaluate cerebral perfusion pressure, which is the difference between mean arterial pressure and intracranial pressure. 

 

For patients with increased ICP, sedatives and CNS depressions need to be avoided because they can alter neurotrax checks. Common order medications include osmotic diuretics like mannitol, and hypertonic saline to decrease edema and corticosteroids to decrease inflammation. In some cases, it might be necessary to prepare the patient for a surgical intervention, like a craniectomy. This will remove a portion of the skull to allow space for swelling or placement of an external ventricular drain in the event of an elevated ICP. 

 

The EVD or external ventricular drain should be leveled to the tray, to be approximately in line with the fourth ventricle of the brain. Any increase in ICP above seven to eight would cause cerebrospinal fluid to drain because 10 centimeters of water correlates to approximately seven to eight millimeters of mercury ICP. If that EVD is not leveled properly, too much or too little cerebrospinal fluid could drain and too little drainage could cause increased ICP and possible brain herniation. Because of medications given to manage ICP like mannitol, it is important to monitor electrolytes and urine output. Mannitol and hypertonic saline can increase sodium levels, which could cause fluctuation in sodium levels, which could lead to seizures. Urine output should be monitored to verify diuresis. There are certain interventions that are utilized to minimize ICP, like maintaining the head of the bed between 30 and 45 degrees. Below 30 and above 45 can both increase ICP. You also want to decrease stimuli as agitation can increase ICP in your patient, and avoid Valsalva maneuvers because coughing and bearing down can increase ICP also. 

 

Here is a look at the completed care plan for increased ICP. Let’s do a quick review. Increased ICP occurs when there is an increase in pressure in the brain cavity or skull, which compresses the brain tissue and leads to neuron changes and damage. Subjective data includes confusion and memory loss. Objective data includes altered LOC, pupil changes, Babinski reflex, seizures, Cushing’s triad, posturing, and elevated temperature. Provide frequent neuro checks every hour to decrease complications. Monitor your patient’s temperature, their hemodynamics, electrolytes and their urine output. Avoid sedatives and CNS depressants to prevent alterations in your neuro checks. Administer osmotic diuretics and corticosteroids. Level and zero your EVD.   Perform interventions like keeping the head of the bed at between 30 and 45 degrees, and decreasing stimuli to prevent increases in ICP. Finally prepare the patient for a craniectomy or EVD placement if necessary.

 

We love you guys. That is it for this lesson on the care plan for increased ICP. Go out and be your best self today and as always, happy nursing!

 

View the FULL Transcript

When you start a FREE trial you gain access to the full outline as well as:

  • SIMCLEX (NCLEX Simulator)
  • 6,500+ Practice NCLEX Questions
  • 2,000+ HD Videos
  • 300+ Nursing Cheatsheets
Start Free Trial