Regulators, Mount Up!
Define intracranial regulation.
What is:
the maintenance of balance to promote an environment conducive to optimal brain function.
Define the condition "Increased Intracranial Pressure" aka IICP.
What is:
a pathologic condition or trauma that causes pressure within the cranial vault to increase
Define the term "brainstem herniation."
What is:
untreated cerebral edema that causes fluid to escape into the foramen of Monro of the brainstem, causing irreversible damage and possibly death
List the lifestyle modifications necessary to improve ICP regulation.
What is:
-healthy diet
-moderate exercise
-avoidance of tobacco products
-control of HTN
-prevention of injury
Describe the diagnostic tools that may be used during the assessment of a patient with possibly impaired ICP regulation.
-mental status testing: mood, cognitive function, personality
-cranial nerve testing: diagnose affected area of brain
-Glasgow coma scale
-NIHSS
What is the normal ICP range for optimal brain function?
What is:
less than or equal to 15mmHg
Give the defining range for IICP.
What is greater than or equal to 20mmHg
List the complications associated with impaired ICP regulation.
What is:
-cerebral edema, papilledema
-IICP
-periorbital bruising
-Cushing's Triad
-CVVI palsies
Name the proper nursing interventions needed to manage IICP.
What is:
-elevate the HOB 35 degrees, depending on if a drain is present.
-manage airway
-use hyperventilation as a temporary solution, while monitoring ABGs
-use stool softeners to avoid straining
-therapeutic hypothermia
-monitor for chewing/swallowing ability
-monitor for persistent H/A and vomiting
List the diagnostic imaging tests that would be used for a patient with suspected IICP.
-MRI
-CT without contrast
-ECG
-brain biopsy
-LP with drainage tube placement
Explain the initial responses to an increase in a brain component.
What is:
shunting or displacement of CSF or increased rate of absorption of CSF
Describe the causes of IICP.
What is:
-Mass Effect: tumor, abscess causing decreased BP, blood flow, and oxygenation
-Increased CSF: tumor
-Decreased Reabsorption of CSF: obstructive hydrocephalus, granulomas
-Increased Blood Volume: ruptured aneurysm, hypercarbia, venous stasis thrombosis, Tetracycline
Describe the defining characteristics of a patient with a brainstem herniation.
What is:
-doll's eyes
-Cheyne-Stokes respirations
-lack of movement
Describe the surgical interventions that may be performed to resolve IICP.
What is:
-craniotomy: remove lesions, repair damaged area, drain blood
-decompressive craniectomy: remove portion of skull to decrease ICP
-stereotactic procedures
-shunt procedures: provides alternate pathway for CSF
The experienced nurse should know the normal rate of CSF production, which is:
What is: 20mL/hr
Name the 4 components necessary for optimal brain function.
What is:
-Perfusion: must be a consistent flow of blood to brain; lack of impairs brain function and leads to tissue death
-Neurotransmission: must be adequate transmission of impulses (impairment can lead to Alzheimer's)
-Healthy Brain Tissue
-Glucose Regulation
List the EARLY signs and symptoms for IICP.
What is:
-Adults: persistent H/A, change in LOC, drowsiness, flat affect, N/V, sluggish pupils
-Infants: irritability, lethargy, poor feeding, bulging fontanels
Define the characteristics of Cushing's triad.
What is:
-widened pulse pressure
-bradycardia
-change in respirations
List possible medications that would be administered to control impaired ICP regulation.
What is:
-Osmotic Diuretics (Mannitol)
-Sedatives (Propofol, Ativan)
-Analgesics (Fentanyl, Morphine)
-Glucocorticoids (Dexamethasone)
-Antipyretics (Acetaminophen)
-Antihypertensives: depends on CPP
-Antiparkinsonian MedsL increase dopamine (Levodopa, Carbidopa, MAO-B Inhibitors)
-Cholinesterase Inhibitors (Acetylcholine)
Which risk factors would a nurse investigate for in a patient with suspected IICP?
What is:
-old age: atrophy, slowed neurotransmission, falls
-young adults: traumatic injury
-smoking
-diabetes, obestity
-cardiovascular disease, HTN
Describe what is meant by the Monroe Kellie Doctrine.
What is:
-The total volume in the skull cannot change.
-With insult to the brain, the increase in volume of one component must be compensated for by a decrease in the volume of another component in the brain.
List the LATE signs and symptoms associated with IICP.
What is:
-positive Babinski sign, nuchal rigidity, increased BP, decreased HR, decreased RR, Cushing's triad, loss of gag reflex and corneal reflex
Which complications can lead to an increase in CPP?
What is:
-hypoxia
-hypercapnia
Explain the term "Cerebral Perfusion Pressure" and its associated normal values.
What is:
-the amount of force available to deliver blood to the brain (MAP-ICP)
-Normal CPP: 60-80mmHg
-Supported CPP: 50-70mmHg