Intracranial Pressure & Care Basics
The normal range for intracranial pressure (ICP)?
What is 5-15 mmHg.
The earliest sign of impaired intracranial regulation
Altered level of consciousness (LOC)
Why is it important to avoid hyperflexion or hyperextension of the neck in clients with increased ICP?
These positions can impede venous outflow from the brain, increasing ICP.
What does the acronym BE FAST stand for in stroke recognition?
Balance, Eyes, Face, Arms, Speech, Time.
The time window for administering fibrinolytics, such as alteplase (tPA), in clients with ischemic stroke?
Within 4.5 hours
This cushions and protects the brain and spinal cord, removes waste, and helps regulate intracranial pressure.
What is CSF
The 3 components of the Glasgow Coma Scale
1. Eye Opening
2. Verbal Response
3. Motor Response
Why is normothermia or permissive hypothermia a therapeutic goal for clients with intracranial dysregulation?
Fever increases metabolic demand in the brain, which can worsen swelling and intracranial pressure.
A temporary disruption of bloodflow to the brain. This can cause stroke-like stymptoms that resolve <24 hours and do not have residual deficits.
What is a Transient Ischemic Attack (TIA)
Name one absolute contraindication for the use of fibrinolytics in clients with ischemic stroke.
Age >80
Anticoagulation regardless of INR, PTT, aPTT
Evidence via imaging of ischemic injury involving more than ⅓ of the brain tissue supplied by the middle cerebral artery (MCA)
Baseline NIH Stroke Scale score >25
History of BOTH stroke and diabetes
Evidence of active bleeding
See Slide 41 (Rationale included)
The pressure needed to ensure blood flow to the brain. It is calculated as mean arterial pressure (MAP) minus intracranial pressure (ICP). A normal range is 60-80 mmHg. It is critical because inadequate CPP can lead to ischemia.
What is Cerebral Perfusion Pressure (CPP). It is critical because inadequate CPP can lead to ischemia.
The 3 components of Cushing's Triad
1. Bradycardia
2. Irregular Respirations
3. Widened Pulse Pressure
Increased and Sustained ICP & Impending Brain Herniation
How hypertonic saline reduces intracranial pressure (ICP).
Hypertonic saline creates an osmotic gradient that draws water out of swollen brain cells into the bloodstream, reducing cerebral edema and intracranial pressure.
What is the primary difference between ischemic and hemorrhagic stroke in terms of pathophysiology?
Ischemic stroke is caused by a blockage of blood flow to the brain, often due to a clot, whereas hemorrhagic stroke results from bleeding into the brain due to a ruptured vessel.
Describe two nursing actions that promote safe feeding in clients affected by stroke.
Describe the Monro-Kellie Doctrine as it relates to ICR/ICP
The Monro-Kellie Doctrine states that the cranial cavity is a fixed space, and the volume is made up of three components: brain tissue, cerebrospinal fluid (CSF), and blood. An increase in one component must be compensated by a decrease in another to maintain normal ICP. If compensation fails, ICP rises.
A lack of voluntary coordination of muscle movements, often resulting in clumsiness or an unsteady gait. It is assessed on the NIHSS by evaluating finger-to-nose or heel-to-shin coordination to identify cerebellar dysfunction.
What is Ataxia
Identify 4 methods that may used to manage increased ICP.
1. Neutral Alignment
2. Osmotic Diuretics (Manitol) / Loop
3. Hypertonic Saline
4. HOB elevation 30-45
5. Ventriculostomy
6. Sedation
7. Low Stimuli Environment
8. Craniectomy
9. Temperature Regulation (higher temp = higher metabolic demands / oxygen consumption)
10. Seizure Prophylaxis
11. Hyperventilation (short term)
Identify 4 modifiable risk factors for stroke
The primary purpose of administering nimodipine to a client after surgery for a subarachnoid hemorrhage
To prevent cerebral vasospasm and improve neurological outcomes
A client is admitted with a traumatic brain injury and has a ventriculostomy in place. The nurse notes an ICP of 22 mmHg and a CPP of 55 mmHg. Which action should the nurse perform first?
Ensure the head of the bed is elevated to 30 degrees and neutral body alignment.
Consider: Least invasive to most invasive. Align the body and get HOB up first. Remember: Avoid calling the provider until you've completed your assessment.
A client arrives in the emergency department with new onset slurred speech, left-sided weakness, and facial drooping. Which action should the nurse take first?
1. Administer oxygen at 2 L/min via nasal cannula.
2. Perform a swallow screen.
3. Check the client’s blood glucose level.
4. Prepare the client for a CT scan of the head.
3. Check the client’s blood glucose level.
Hypoglycemia can mimic stroke symptoms, and it must be ruled out before proceeding with further interventions. Once hypoglycemia is excluded, a CT scan is critical to differentiate between ischemic and hemorrhagic stroke.
A client with increased intracranial pressure is receiving hypertonic saline therapy. Serial sodiums are ordered. The nurse notes a serum sodium level of 152 mEq/L and reports it to the healthcare provider. What is the nurse’s priority action?
3. Assess the client for signs of fluid overload or pulmonary edema.
Hypertonic saline therapy can lead to hypernatremia and fluid shifts, increasing the risk of complications such as fluid overload and pulmonary edema. While notifying the provider and adjusting the infusion may follow, assessing for complications is the immediate priority. Remember: Treat the Patient, not the Number.
A client presents to the emergency department with slurred speech and left-sided weakness that began 90 minutes ago. The client’s blood glucose level is 120 mg/dL. What is the nurse’s next priority action?
1. Notify the stroke team and prepare for a head CT scan.
2. Administer aspirin as prescribed to prevent clot formation.
3. Perform a complete neurological assessment and reassess symptoms.
4. Obtain informed consent for fibrinolytic therapy.
Notify the stroke team and prepare for a head CT scan.
A CT scan is essential to differentiate between ischemic and hemorrhagic stroke before initiating any further treatment, such as fibrinolytic therapy. Aspirin and fibrinolytics are contraindicated in hemorrhagic strokes, making imaging the next critical step.
A client with an ischemic stroke received alteplase (tPA) 2 hours ago. Which finding requires the nurse to contact the provider immediately?
4. Sudden decrease in level of consciousness.
Rationale: A decrease in consciousness after tPA administration may indicate intracranial hemorrhage, a serious complication requiring immediate intervention