Unit 7 Chaper 41 Increased Intracranial Pressure, Craniotomy

Question 1

Why is ICP detrimental?

Answer 1

Within this space, there is li ttle room for any of the components to expand or increase in volume.
With ICP it can shift lobes of the brain and also cause a CSF leak
Cranium is closed cavity, therefore does not allow for swelling

Question 2

What is the normal ICP? Can Increased ICP cause death?

Answer 2

A normal level of intracranial pressure (ICP) is 10 to 15 mm Hg. Periodic increases in pressure occur with straining during defecation, coughing, or sneezing but do not harm the uninjured brain. A sustained ICP of greater than 20 mm Hg is considered detrimental to the brain because neurons begin to die.

Question 3

What is the tx for ICP

Answer 3

Mannitol

Question 4

If the brain swells, is there an increase in intracranial pressure?
A. Yes
B. No

Answer 4

A.YES

If any of these increase in size, there is an increase in pressure:
* If the brain swells
* If the tissues around the brain swells
* If there is too much CSF
* If the blood vessels vasodilate

Question 5

Complication of ICP

Answer 5

If the pressure is too high – continuously gets worse if not treated:
Which causes cerebral edema

If too high, the brain herniates down through the hole at bottom of
skull (Foramen Magnum) and leads to brain stem dysfunction
* Brain stem controls vital signs
* Changes in HR, BP, respiration, and temperature

• Can cause hypoxia of brain
• Hypoxia can lead to brain tissue death
• Brain tissue death leads to increase in “clean up” via increase in WBC to site which leads to
  further intracranial processes (more blood flow) * CO2 accumulation causes vasodilation, which leads to further intracranial processes

Question 6

Increased ICP is the leading cause of death from head trauma in patients who reach the hospital alive.

Answer 6

Increased ICP is the leading cause of death from head trauma in patients who reach the hospital alive.

Question 7

What is the main goal for ICP?

Answer 7

prevent ICP

Question 8

Can ICP cause brain death?

Answer 8

YES
If edema remains untreated, the brainstem may herniate downward through the foramen of Monro or laterally from a unilateral lesion within one cerebral hemisphere,causing irreversible brain damage and possibly death (from brain herniation syndromes discussed later)

Question 9

Causes of ICP

Answer 9

Trauma (Ex: falls, or MVA) – swelling and bruising

• Blood flow comes along to make the bruise and to take away the blood cells
  as bruises go away (think about a bruise on your arm or leg where you can see it.)
• Disease – infection
• Increase in WBC to site of infection
• Inflammation
• Hemorrhagic stroke – extra blood in area

Question 10

S/S OF ICP

Answer 10

Initially: Altered LOC, restlessness, HA, confusion

• Vomiting—projectile or recurrent
• Unequal pupils and abnormal response
• Blown pupils—late sign of herniation
• Posturing—decorticate, decerebrate, flaccid

Question 11

Is cushings triad an early or late sign of ICP?
A. early
B. late

Answer 11

B. late

Question 12

What are the s/s of Cushing’s triad?

Answer 12

CHANGE IN VITAL SIGNS:
Cushing’s Triad
* Bradycardia
* Rising systolic BP (severe HTN)
* Widened pulse pressure
* Slow respiratory rate
*Cheyne stroke respirations

Question 13

Decerebrate

Answer 13

A person whose limbs all extend away from their head has decerebrate posturing.

Question 14

Decorticate

Answer 14

A person whose elbows bend and fold their arms up toward their chest has decorticate posturing. A

Question 15

Which abnormal posturing is more severe?
Decorticate or Decerebrate

Answer 15

Decorticate or Decerebrate posturing develops when ICP is increased.

Decerebrate posturing means there is damage to the brainstem, which is
serious

Question 16

What fluid and electrolyte balance requires immediate attention?
A. Potassium 4.9
B. Sodium 110.0
C. Calcium 10.0
D. magnesium 1.5

Answer 16

B. Sodium 110.0
Low sodium induces seizure

Monitor fluid and electrolyte imbalances
* Daily weights
* Accurate I&O’s

Question 17

If there is trauma to the head what disease process should you monitor for that is associated with the anti diuretic hormone

Answer 17

(Diabetes insipidus/SIADH)

Question 18

Nursing Intervention for Managing or preventing ICP

Answer 18

Elevate the HOB 30 degrees unless contraindicated by medical
condition and position in correct body alignment –
avoid flexion or extension of neck & maintain head in midline neutral position
Log roll patient & avoid hip flexion Decrease cerebral edema–osmotic diuretics like mannitol & possible
fluid restriction
* Lower CSF fluid–using an intraventricular drain system *
Maintain cerebral perfusion–monitor C.O., manage IV fluids carefully,
no cluster care
quiet environment
avoid flexion
inotropes if needed
MAP ATLEAST 65

Question 19

Nursing Intervention for Managing ICP Continued

Answer 19

Controlling fever with antipyretics or gently cool with a cooling blanket – do not allow the patient to shiver – it will increase ICP
no cluster care
* Oxygenation–monitor ABG’s, pulse oximetry, Hgb levels and hyperventilate to decrease CO2 (increased PaCO2 causes
vasodilation)
Important to hyperoxygenate, not hyperventilate * Reduce cellular metabolic demands–barbiturates and/or sedation
quiet environment

Question 20

Prior to suctioning what is the first intervention

Answer 20

(hyperoxygenatate 100%

Question 21

Your patient with meningitis, has suddenly combative and irritable, what assessment should you initiate first?
A. Physical Assessment
B. Neurological Assessment
C. Respiratory assessment
D. Cardiovascular assessment

Answer 21

B. Neurological Assessment

Question 22

Your patient with meningitis, suddenly exhibits. cheyne stroke respiration. What assessment should you initiate first?
A. Physical Assessment
B. Neurological Assessment
C. Respiratory assessment
D. Cardiovascular assessment

Answer 22

B. Neurological Assessment

Respiratory patterns can change with brain injuries
* Review respiratory patterns
* Cheyne stokes, Biot’s, et

Question 23

What is the surgical management for Increased Cranial Pressure?
A. Thoracentesis
B. Paracentesis
C. Hyposphoectomy
D. Craniostomy

Answer 23

D. Craniotomy, usually used to remove tumors

Question 24

What are the complications of craniotomy?

Answer 24

DI AND SIADH

Question 25

Action alert post op Craniotomy

Answer 25

Assess neurologic and vital signs every 15 to 30 minutes for the first 4 to 6 hours after a craniotomy and then every hour. If the patient is stable for 24 hours, the frequency of these checks may be decreased to every 2 to 4 hours, depending on agency policy and the patient’s condition. Report immediately and document new neurologic deficits, particularly a decreased level of consciousness (LOC), motor weakness or paralysis, aphasia, decreased sensory perception, and sluggish pupil reaction to light! Personality changes such as agitation, aggression, or passivity can also indicate worsening neurologic status.

Question 26

Post op care

Answer 26

Post-op Care:
* Neuro and dressing checks every hour
* HOB up 30 degrees
- avoid extreme hip or neck flexion, maintain head midline,
neutral position to prevent
Increased ICP
* I&O due to the possibility of sustaining DI OR SIADH

Question 28

Nursing intervention for DI

Answer 28

IV fluid increase

Question 29

Nursing intervention for SIADH

Answer 29

Iv fluid restriction**
Sodium replacamanet
furosemide

Question 30

Goal Post Op craniotomy

Answer 30

After craniotomy, monitor the patient’s dressing for excessive amounts of drainage. Report a saturated head dressing or drainage greater than 50 mL/8 hr immediately to the surgeon! Monitor frequently for signs of increasing ICP!

Question 31

Your client who has just undergone a craniotomy appears to restless an irritable What is the nurses first intervention?
A. elevate the HOB 30 degrees
B. play loud music
C. administer PO mannitol
D. Administer setraline

Answer 31

A. elevate the HOB 30 degrees

Symptoms of increased ICP include severe headache, deteriorating LOC, restlessness, and irritability. Dilated or pinpoint pupils that are slow to react or nonreactive to light are late signs of increased ICP.

After craniotomy, monitor the patient’s dressing for excessive amounts of drainage. Report a saturated head dressing or drainage greater than 50 mL/8 hr immediately to the surgeon! Monitor frequently for signs of increasing ICP!

Question 32

When should you hyperoxegenate your client prior to suctioning?

Answer 32

Remember to hyperoxygenate the patient carefully before, during, and after suctioning!

Question 33

Is seizure a potential complication of ICP?

Answer 33

Seizures are a potential complication that can occur at any time for as long as 1 year or more after surgery.

Provide the patient and family with information about seizure precautions and what to do if a seizure occurs.

Teach the need for follow-up appointments to monitor for therapeutic levels of antiepileptic drugs (AEDs).

Question 34

Patient teaching seizure precautions

Answer 34

Provide the patient and family with information about seizure precautions and what to do if a seizure occurs.

Teach the need for follow-up appointments to monitor for therapeutic levels of antiepileptic drugs (AEDs).

Question 35

Intracranial Monitoring and Drainage

Answer 35

Monitors and drains can be placed within the cranial cavity
* Monitor for noxious stimuli,
avoid clustering care
* Assess for CSF leaks

After craniotomy, monitor the patient’s dressing for excessive amounts of drainage. Report a saturated head dressing or drainage greater than 50 mL/8 hr immediately to the surgeon! Monitor frequently for signs of increasing ICP!