MS Exam 4 BP (1).
Med Surg Exam 4 Blueprint
NURSING MANAGEMENT: ACUTE INTRACRANIAL PROBLEMS (13)
1. Describe the common etiologies, clinical manifestations, interprofessional care,
medication therapy, and nursing management of the patient with increased intracranial
pressure (6) Cait
● Normal ICP 5-15 mmHg
● Common etiologies:
○ Increase in any or all of the 3 components within the skull
■ Brain tissue
■ Blood
■ CSF
○ Common causes of increased ICP:
■ A mass (hematoma, contusion, abscess, tumor)
■ Cerebral edema (associated with brain tumors, hydrocephalus, head
injury, brain inflammation, cerebral infections, or vascular insult)
○ Factors that influence ICP
■ Arterial pressure
■ Venous pressure
■ Intraabdominal and intrathoracic pressure
■ Posture
■ Temperature
■ Blood gases (CO2 levels)
● Clinical manifestations:
○ Change in LOC- most sensitive and reliable indicator
○ Change in vital signs
■ Cushing's triad- may not appear till ICP is increased for some
time MED EMERGENCY
● Systolic HTN with widening pulse pressure
● Bradycardia with full and bounding pulse
● Irregular respirations
■ Change in body temperature
○ Compression of CN III
■ Dilation of pupil on same side as mass lesion
■ Sluggish or no response to light
■ Inability to move eye upward and adduct
■ Ptosis of the eyelid
■ A fixed, unilateral, dilated pupil = neuro emergency, herniation of the
brain
○ Other CN nerves
■ Diplopia
■ Blurred vision
■ Changes in extraocular eye movements
■ Papilledema- nonspecific sign associated with persistent increased ICP
○ Decrease in motor function
■ hemiparesis/hemiplegia
■ Decerebrate posturing
(extensor)- indicates more
serious damage
,MS Exam 4 BP (1).
● Arms stiffly extended, adducted, and hyperpronated
● Legs hyperextended with plantar flexion of feet
■ Decorticate posturing (flexor)
● Internal rotation and adduction of the arms with flexion of
the elbows, wrists, and fingers; extension of legs may be
present
○ Headache
■ Often continuous
■ Nocturnal and/or in the morning
■ Straining, agitation, or movement accentuate the pain
○ Vomiting
■ Not preceded by nausea
■ Projectile
● Interprofessional care:
○ Treat underlying cause
○ Adequate oxygenation
■ PaO2 > 100 mmHg
■ PaCO2 35-45 mmHg
■ Intubation
■ Mechanical ventilation
○ Surgery- craniectomy (removal of part of the skull)
○ Nutritional therapy:
■ Hypermetabolic and hypercatabolic state- increased need for glucose
■ Enteral or parenteral nutrition
■ Early feeding (within 3 days of injury)
■ Keep patient normovolemic
■ IV 0.9% NaCl preferred over D5W or 0.45% NaCl
○ Fever control:
■ Antipyretics
■ Cool baths
■ Cooling blankets
■ Ice packs
■ Intravascular cooling device
○ Quiet, calm environment with minimal noise and interruptions
● Medication therapy:
○ Mannitol
■ IV osmotic diuretic
■ Decreases ICP by plasma expansion & osmotic effect
■ Monitor fluid and electrolyte status
■ Contraindicated if renal disease is present and serum osmolality is
elevated
○ Hypertonic saline
■ Moves water out of cells and into blood
■ Monitor BP and serum sodium levels
■ Often used concurrently with mannitol
○ Corticosteroids- dexamethasone
■ NOT recommended for traumatic brain injury
■ Vasogenic edema
■ Monitor fluid intake, serum sodium and glucose levels
■ Concurrent antacids, H2 receptor blockers, PPIs
,MS Exam 4 BP (1).
■ Complications- hyperglycemia, infection, GI bleeding
○ Antiseizure medications- phenytoin
○ Antipyretics- avoid letting pt shiver
○ Sedatives
○ Analgesics
○ Barbiturates- pentobarbital, thiopental
■ Total burst suppression, absence of spikes showing brain activity
on the EEG monitor, indicated maximal therapeutic effect is
achieved
● Nursing management:
○ Assessment:
■ LOC
■ Glasgow Coma Scale
● Highest score- 15; lowest- 3
● <8 indicated coma, mechanical ventilation should be considered
■ Pupillary check for size and response
■ Cranial nerves
● Eye Movements
● Corneal reflex
● Oculocephalic reflex (doll’s eye reflex)
● Oculovestibular (caloric stimulation)
■ Motor strength
● Squeeze hands
● Pronator drift test
● Raise foot off bed or bend knees
■ Motor response
● Spontaneous or to pain
■ Vital signs
○ Diagnostics:
■ CT/ MRI/ PET
■ EEG
■ Cerebral angiography
■ ICP and brain tissue oxygenation measurement (LICOX catheter)
■ Doppler and evoked potential studies
■ Labs- CBC, ABGs, electrolytes, etc
■ CSF analysis
■ NO LUMBAR PUNCTURE
■ Measuring ICP:
● Ventriculostomy- GOLD STANDARD
○ Catheter inserted into lateral ventricle, coupled with an
external transducer; needs to be level with tragus of
the ear (interventricular foramen)
● Fiberoptic catheter- sensor transducer located within catheter tip
● Air pouch/pneumatic technology- air-filled pouch at catheter tip
○ Acute care:
■ Respiratory function:
● Maintain patent airway
● Elevate HOB 30 degrees
● Suctioning needs
, MS Exam 4 BP (1).
○ <10 seconds; 100% O2 before and after
○ Limit to 2 passes per suction procedure
○ Avoid cumulative increase in ICP with suctioning
● Snoring sounds indicate obstruction
● Minimize abdominal distention- insert NG tube
● Monitor ABGs
● Maintain ventilatory support
■ Pain and anxiety management
● Opioids- morphine & fentanyl
● Propofol- for anxiety & agitation
○ Accurate neuro assessment soon after turning off infusion
● Dexmedetomidine- alpha 2 agonist
○ For continuous IV sedation for up to 24 hrs
○ SE- hypotension
● Neuromuscular blocking agents
○ Vecuronium, cisatracurium
○ For achieving complete ventilatory control in tz of
refractory intracranial hypertension
● Benzodiazepines
○ Usually avoided unless used with neuromuscular
blocking agents
■ Fluid & electrolyte balance
● Monitor IV fluids
● Daily electrolytes
● Monitor for DI or SIADH
● I&Os
● Daily weights
■ Interventions to optimize ICP and CPP
● HOB elevated 30 degrees
○ Over 30 degrees may decrease CPP by lowering systemic
BP
● Prevent extreme neck flexion- can cause venous obstruction=
increase ICP
● Maintain pt in head up & midline position
● Turn slowly
● Turn q 2hrs
● Use calm, reassuring approach
● Touch & talk to pt, even if in a coma
● Avoid coughing, straining, Valsalva, sneezing, suctioning,
hypoxemia, arousal from sleep (increase ICP)
● Avoid hip flexion
● Skin care
■ Minimize complications of immobility
■ Protection from self-injury
● Judicious use of restraints; sedatives (midazolam or lorazepam)
● Have family at bedside
● Seizure precautions
○ Padded side rails
○ Airway at bedside
Med Surg Exam 4 Blueprint
NURSING MANAGEMENT: ACUTE INTRACRANIAL PROBLEMS (13)
1. Describe the common etiologies, clinical manifestations, interprofessional care,
medication therapy, and nursing management of the patient with increased intracranial
pressure (6) Cait
● Normal ICP 5-15 mmHg
● Common etiologies:
○ Increase in any or all of the 3 components within the skull
■ Brain tissue
■ Blood
■ CSF
○ Common causes of increased ICP:
■ A mass (hematoma, contusion, abscess, tumor)
■ Cerebral edema (associated with brain tumors, hydrocephalus, head
injury, brain inflammation, cerebral infections, or vascular insult)
○ Factors that influence ICP
■ Arterial pressure
■ Venous pressure
■ Intraabdominal and intrathoracic pressure
■ Posture
■ Temperature
■ Blood gases (CO2 levels)
● Clinical manifestations:
○ Change in LOC- most sensitive and reliable indicator
○ Change in vital signs
■ Cushing's triad- may not appear till ICP is increased for some
time MED EMERGENCY
● Systolic HTN with widening pulse pressure
● Bradycardia with full and bounding pulse
● Irregular respirations
■ Change in body temperature
○ Compression of CN III
■ Dilation of pupil on same side as mass lesion
■ Sluggish or no response to light
■ Inability to move eye upward and adduct
■ Ptosis of the eyelid
■ A fixed, unilateral, dilated pupil = neuro emergency, herniation of the
brain
○ Other CN nerves
■ Diplopia
■ Blurred vision
■ Changes in extraocular eye movements
■ Papilledema- nonspecific sign associated with persistent increased ICP
○ Decrease in motor function
■ hemiparesis/hemiplegia
■ Decerebrate posturing
(extensor)- indicates more
serious damage
,MS Exam 4 BP (1).
● Arms stiffly extended, adducted, and hyperpronated
● Legs hyperextended with plantar flexion of feet
■ Decorticate posturing (flexor)
● Internal rotation and adduction of the arms with flexion of
the elbows, wrists, and fingers; extension of legs may be
present
○ Headache
■ Often continuous
■ Nocturnal and/or in the morning
■ Straining, agitation, or movement accentuate the pain
○ Vomiting
■ Not preceded by nausea
■ Projectile
● Interprofessional care:
○ Treat underlying cause
○ Adequate oxygenation
■ PaO2 > 100 mmHg
■ PaCO2 35-45 mmHg
■ Intubation
■ Mechanical ventilation
○ Surgery- craniectomy (removal of part of the skull)
○ Nutritional therapy:
■ Hypermetabolic and hypercatabolic state- increased need for glucose
■ Enteral or parenteral nutrition
■ Early feeding (within 3 days of injury)
■ Keep patient normovolemic
■ IV 0.9% NaCl preferred over D5W or 0.45% NaCl
○ Fever control:
■ Antipyretics
■ Cool baths
■ Cooling blankets
■ Ice packs
■ Intravascular cooling device
○ Quiet, calm environment with minimal noise and interruptions
● Medication therapy:
○ Mannitol
■ IV osmotic diuretic
■ Decreases ICP by plasma expansion & osmotic effect
■ Monitor fluid and electrolyte status
■ Contraindicated if renal disease is present and serum osmolality is
elevated
○ Hypertonic saline
■ Moves water out of cells and into blood
■ Monitor BP and serum sodium levels
■ Often used concurrently with mannitol
○ Corticosteroids- dexamethasone
■ NOT recommended for traumatic brain injury
■ Vasogenic edema
■ Monitor fluid intake, serum sodium and glucose levels
■ Concurrent antacids, H2 receptor blockers, PPIs
,MS Exam 4 BP (1).
■ Complications- hyperglycemia, infection, GI bleeding
○ Antiseizure medications- phenytoin
○ Antipyretics- avoid letting pt shiver
○ Sedatives
○ Analgesics
○ Barbiturates- pentobarbital, thiopental
■ Total burst suppression, absence of spikes showing brain activity
on the EEG monitor, indicated maximal therapeutic effect is
achieved
● Nursing management:
○ Assessment:
■ LOC
■ Glasgow Coma Scale
● Highest score- 15; lowest- 3
● <8 indicated coma, mechanical ventilation should be considered
■ Pupillary check for size and response
■ Cranial nerves
● Eye Movements
● Corneal reflex
● Oculocephalic reflex (doll’s eye reflex)
● Oculovestibular (caloric stimulation)
■ Motor strength
● Squeeze hands
● Pronator drift test
● Raise foot off bed or bend knees
■ Motor response
● Spontaneous or to pain
■ Vital signs
○ Diagnostics:
■ CT/ MRI/ PET
■ EEG
■ Cerebral angiography
■ ICP and brain tissue oxygenation measurement (LICOX catheter)
■ Doppler and evoked potential studies
■ Labs- CBC, ABGs, electrolytes, etc
■ CSF analysis
■ NO LUMBAR PUNCTURE
■ Measuring ICP:
● Ventriculostomy- GOLD STANDARD
○ Catheter inserted into lateral ventricle, coupled with an
external transducer; needs to be level with tragus of
the ear (interventricular foramen)
● Fiberoptic catheter- sensor transducer located within catheter tip
● Air pouch/pneumatic technology- air-filled pouch at catheter tip
○ Acute care:
■ Respiratory function:
● Maintain patent airway
● Elevate HOB 30 degrees
● Suctioning needs
, MS Exam 4 BP (1).
○ <10 seconds; 100% O2 before and after
○ Limit to 2 passes per suction procedure
○ Avoid cumulative increase in ICP with suctioning
● Snoring sounds indicate obstruction
● Minimize abdominal distention- insert NG tube
● Monitor ABGs
● Maintain ventilatory support
■ Pain and anxiety management
● Opioids- morphine & fentanyl
● Propofol- for anxiety & agitation
○ Accurate neuro assessment soon after turning off infusion
● Dexmedetomidine- alpha 2 agonist
○ For continuous IV sedation for up to 24 hrs
○ SE- hypotension
● Neuromuscular blocking agents
○ Vecuronium, cisatracurium
○ For achieving complete ventilatory control in tz of
refractory intracranial hypertension
● Benzodiazepines
○ Usually avoided unless used with neuromuscular
blocking agents
■ Fluid & electrolyte balance
● Monitor IV fluids
● Daily electrolytes
● Monitor for DI or SIADH
● I&Os
● Daily weights
■ Interventions to optimize ICP and CPP
● HOB elevated 30 degrees
○ Over 30 degrees may decrease CPP by lowering systemic
BP
● Prevent extreme neck flexion- can cause venous obstruction=
increase ICP
● Maintain pt in head up & midline position
● Turn slowly
● Turn q 2hrs
● Use calm, reassuring approach
● Touch & talk to pt, even if in a coma
● Avoid coughing, straining, Valsalva, sneezing, suctioning,
hypoxemia, arousal from sleep (increase ICP)
● Avoid hip flexion
● Skin care
■ Minimize complications of immobility
■ Protection from self-injury
● Judicious use of restraints; sedatives (midazolam or lorazepam)
● Have family at bedside
● Seizure precautions
○ Padded side rails
○ Airway at bedside
