NURSING CARE RELATED TO THE SENSORY AND
NEUROLOGICAL SYSTEMS
2-40
2-40. INCREASED INTRACRANIAL PRESSURE
a. Definition. The cranium is a closed cavity filled with contents that are virtually noncompressible. Rapid or prolonged increases in an intracranial pressure present a serious threat to life. This increased pressure may result from edema, bleeding, trauma, or space-occupying lesions. Once the pressure exceeds the accommodation point, the brain will herniate through weak points (for example, the foramen magnum). Irreversible neurological damage or death will result.
b. Signs and Symptoms of Increased Intracranial Pressure.
(1) Change in level of consciousness.
(a) May occur over a period of minutes, hours, or days.
(b) Characterized by a diminished response to environmental stimuli.
(c) Responsiveness ranges from alert and oriented to no response to stimuli.
(d) Confusion, restlessness, disorientation, and drowsiness may be signs of an impending change.
(2) Headache--increases in severity with coughing, sneezing, or straining at stool.
(3) Vomiting.
(4) Papilledema/pupil changes.
(a) Edema and pressure of both the optic nerve and the oculomotor nerve at the point at which they enter the globe is caused by venous congestion resulting from increased intracranial pressure.
(b) Pupil on the affected side may be nonreactive.
(c) Pupils may be unequal, dilated, pinpoint, or nonreactive.
(5) Elevation of blood pressure with a widened pulse pressure.
(6) Decreased pulse rate (may be increased initially).
(7) Decreased respiratory rate (may be irregular).
c. Nursing Management.
(1) Monitor vital signs closely.
(a) Accurately assess and document neurological status.
(b) Evaluation of alterations of consciousness is crucial since symptoms progress rapidly.
(2) Maintain patent airway.
(a) Intubation and hyperventilation may be indicated to provide adequate cerebral perfusion of oxygenated blood and decrease carbon dioxide induced vascular spasm.
(b) If patient is not intubated, position the patient on his side to decrease the possibility of airway occlusion; use oral or nasopharyngeal airway, prn.
(c) Be aware that stimulation of coughing when suctioning increases intracranial pressure and may precipitate seizure activity.
(3) Administer medications as ordered.
(a) Mannital (osmotic diuretic, to decrease cerebral edema).
(b) Corticosteroids (to reduce cerebral edema).
(c) Dilantin (as a precautionary measure to prevent seizure activity).
(d) Antibiotics.
(4) Elevate head of bed (30º).
(a) Promotes return of venous blood.
(b) Under no circumstances should patient's head be lower than the body.
(5) Administer hypertonic I.V. solutions as ordered.
(a) Dextrose in water (hypotonic) crosses the blood-brain barrier and increase cerebral edema and intracranial pressure.
(b) Fluids will be restricted to reduce intracranial pressure.
(c) Accurate intake and output records must be kept.
(6) Protect patient from injury should seizures occur.
(a) Pad side rails.
(b) Secure a tongue blade to the head of the bed for easy access.
(7) Maintain normal body temperature.
(a) Intracranial bleeding is frequently accompanied by increases in body temperature that are resistant to antipyretic agents.
(b) Monitor rectal temperature frequently.
(c) Place patient on hypothermia blanket, as ordered, for temperature over 102ºF.
d. Patient Education. Family members of patients who return home following injury to the head should be instructed to return the patient to the hospital if any of the following problems occur.
(1) Fever greater than 100ºF.
(2) Pulse less than 50 beats per minute.
(3) Vomiting.
(4) Slurred speech.
(5) Dizziness.
(6) Blurred or double vision.
(7) Unequal pupil size.
(8) Blood or fluid discharge from ears or nose.
(9) Increased sleepiness.
(10) Inability to move extremities.
(11) Convulsions.
(12) Unconsciousness.
