Nursing interventions Interventions to reduce or stabilize ICP include raising the head of the bed to thirty degrees, keeping the neck in a neutral position, maintaining a normal body temperature, and preventing volume overload. As the patient enters stage 4, ICP rises to lethal levels with little increase in volume. Hernia occurs when brain tissue forcibly moves from the higher-pressure compartment to a lower-pressure compartment. In this situation, intense pressure is exerted on the brain stem, and if the hernia continues, the death of the brain stem is imminent.
Activate your 30-day free trial to unlock unlimited reading. Activate your 30-day free trial to read on. The rigid cranial vault contains brain tissue (1,400 g), blood (75 ml) and CSF (75 ml). The volume and pressure of these three components are usually in a state of equilibrium and produce ICP.
ICP is usually measured in the lateral ventricles; normal ICP is 10 to 20 mm hg. The Monro-Kellie hypothesis states that, due to the limited space for expansion within the skull, an increase in any of the components causes a change in the volume of the others. Increased ICP is a syndrome that affects many patients with acute neurological conditions. This is because pathological conditions alter the relationship between intracranial volume and pressure.
Although elevated ICP is most often associated with head injury, it can also be seen as a side effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies. Nursing interventions can positively or negatively affect intracranial pressure (ICP). Nurses have a unique opportunity to manage patient care to decrease elevated ICP and prevent secondary brain injury. However, patients should also be diligently monitored for side effects, such as ventilator-associated pneumonia (VAP) and skin breakdown.
It becomes a delicate balance to maintain brain function while helping to prevent other secondary injuries. This increased pressure will compress brain tissue, causing damage to neurons and causing neurological changes and eventually herniation and brain death. 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. Compensatory mechanisms fail, there is a loss of self-regulation, and the patient exhibits manifestations of increased ICP (e.g.
Any increase in ICP above seven to eight would cause cerebrospinal fluid to drain because 10 centimeters of water correlates with approximately seven to eight millimeters of ICP mercury. In short, this hypothesis says that if the volume of one of these structures increases, the others must decrease in volume to help relieve pressure. To describe the collaborative and nursing management of patients with increased intracranial pressure. For patients with increased ICP, sedatives and CNS depressions should be avoided because they may alter neurotrax controls.
Interventions can be initiated at elevated temperatures, sometimes as high as 104 is common with an increase in ICP due to loss of autonomous regulation. Differentiate between the root causes, collaborative care and nursing management of brain abscess, meningitis and encephalitis. If that EVD is not leveled correctly, it could drain too much or too little cerebrospinal fluid, and too little drainage could lead to increased ICP and possible brain herniation. Increased pressure within the cranial cavity (or skull) is due to an increase in the volume of brain tissue, blood or cerebrospinal fluid, or the presence of another lesion that occupies space.
In some cases, it may be necessary to prepare the patient for surgical intervention, such as a cranectomy. When there is an increase in intracranial pressure, the body can temporarily compensate for it by shifting CSF to other areas of the brain or spinal cord (or by decreasing its production) and altering the blood volume that goes to the brain through vasocontrition, but if the pressure is continuous, it cannot compensate. Any patient who is acutely unconscious, regardless of the cause, should be suspected of having an increase in ICP. .