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Pathophysiology
Increased pressure within the cranial cavity (or skull) is caused by an increase in the volume of either the brain tissue, blood, or cerebrospinal fluid, or by the presence of another space-occupying lesion. This increased pressure will compress the brain tissue, causing damage to the neurons and leading to neuro changes and eventually herniation and brain death.
Etiology
Anything that causes the increased volume of brain tissue, blood, or cerebrospinal fluid within the skull - cerebral edema, hemorrhage, hydrocephalus, hypertension, cerebral vasodilation. It could also be caused by a space-occupying lesion such as a tumor or mass.
Desired Outcome
Minimize intracranial pressure to prevent any damage to nerve tissue and prevent long-term neurological deficits.
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
Nursing Interventions and Rationales
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).
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