NEUROLOGICAL
DISORDERS
Care of client
with increased
icp
INCREASED Intracranial
pressure
Intracranial pressure (ICP) is defined
as the pressure within the craniospinal
compartment, a closed system that
comprises a fixed volume of neural tissue,
blood, and cerebrospinal fluid (CSF)
Normal ICP – 5-15 mmHg
ICP is monitored using ICP
monitoring device
INCREASED Intracranial
pressure
Intracranial pressure (ICP) monitoring is a
diagnostic test that determine if high or low
cerebrospinal fluid (CSF) pressure is
causing your symptoms.
The test measures the pressure in your
head directly using a small pressure-
sensitive probe that is inserted through
the skull
INCREASED Intracranial
pressure
INCREASED Intracranial
pressure
CEREBRAL PERFUSION PRESSURE
is the force driving blood into the brain,
providing oxygen and nutrients. Cerebral
perfusion pressure is the primary
determinant of cerebral blood flow (CBF)
Cerebral perfusion pressure is defined as
the difference between the mean arterial
pressure (MAP) and ICP (CPP = MAP −
ICP)
Normal CPP – 60-100mmHg
INCREASED Intracranial
pressure
MEAN ARTERIAL PRESSURE
• MAP is an important measurement that
accounts for flow, resistance, and pressure
within your arteries.
• It allows doctors to evaluate how well
blood flows through your body and
whether it's reaching all your major
organs. Most people do best with a MAP
between 70 and 110 mm Hg
INCREASED Intracranial
pressure
Formula for Cerebral Perfusion
Pressure
CPP= MAP –ICP
HoW to compute for MAP?
MAP = 2 (DBP) + SBP
3
INCREASED Intracranial
pressure
SAMPLE: IF THE BP IS 120/80mmHg;
and
ICP is 12
MAP= 2(DBP) + SBP CPP= MAP-
ICP
3 = 93.3-12
= 2(80) + 120 /3 CPP= 81.3
mmHg
INCREASED Intracranial
pressure
Low CPP- A decrease in the CPP suggests
that the gradient required to push blood
towards the brain is not being maintained. This
can cause brain ischemia from reduced
cerebral blood flow
High CPP-If the BP becomes elevated, the
increased CPP can lead to increased cerebral
blood flow. When combined with increased
capillary permeability or cerebral vasodilation,
blood flow can increase to the point where
brain edema worsens.
INCREASED Intracranial
pressure
• Increased ICP occurs when there is
increase in the bulk of the brain (consist of
brain tissue, blood supply, and CSF)
• Disorders that increase the bulk:
a. Brain tissue- space occupying lesions
e.g cerebral tumors, abscess, edema
(due to infection or trauma)
b. Blood supply – hemorrhage,
thrombosis, embolism, aneurysm (a
ballooning at a weak spot in an artery
wall)
INCREASED Intracranial
pressure
c. CSF- obstruction to the flow of CSF caused
by tumor, ventricular system defects
(hydrocephalus), overproduction of CSF
caused by tumor in CHOROID PLEXUS
• Increased ICP causes
CEREBRAL HYPOXIA (low
oxygen level)
INCREASED ICP
Monro-Kellie’s Theory on Increased ICP
Brain is encage in skull
No room for expansion of the bulk of the
brain
( brain tissue, blood supply, CSF Volume)
If the volume of any one of the three
components of the bulk of the brain increase
Compression of the Brain components
INCREASED ICP
Cerebral Ischemia
Cerebral Hypoxia
Inflammation
Cerebral Edema
Increased Intracranial Pressure
Clinical manifestation
• Initial sign of Increased ICP –
RESTLESSNESS and Altered level of
Consciousness due to affectation of ARAS
(ascending reticular activating system)
• Headache – due to traction on pain
• Nausea and vomiting - due to pressure at
the medulla oblongata (vomiting may be
projectile)
• Diplopia (double vision)- due to pressure
on cranial nerve VI –Abducens (controls
the lateral movement of the eye and it is
the longest cranial nerve; vulnerable for
compression)
Clinical manifestation
• Vital Signs Changes – due to stimulation of
the CUSHING’s Reflex in response to
cerebral hypoxia
a. Blood Pressure
-Systolic BP is elevated due to
increased force in cardiac contractility (
the body’s attempt to increase cerebral
tissue perfusion and oxygenation)
-Diastolic pressure remains normal or
decreased due to longer time required
for the heart to relax
- Widened Pulse Pressure (normal is 30-
40mmHg)
Clinical manifestation
B. Pulse Rate
- Bradycardia with slow bounding pulse
C. Respiratory Rate
- is slow due to involvement of medulla
oblongata and pons
• CUSHING’s TRIAD
1. Widening Pulse Pressure
2. Bradycardia
3. Irregular Respiration
Clinical manifestation
• Puppilary Changes
a. Anisocoria (unequal pupil size) – due to CN III
(Oculomotor) compression
b. Pinpoint pupils indicate pons involvement
c. Fixed, Dilate Pupils indicates brain herniation
cause by compression in the brain stem that
result to cardiopulmonary arrest
• Papilledema – due to compression of optic
nerve (CN II)
• Lateralizing Sign – contralateral (opposite
side) loss of motor function due to
decussation (crossing) of motor fibers at
the level of medulla
Clinical manifestation
• Brainstem Function Impairment
a. DOLL’s Eye Sign- dysconjugate movement of
the eyes as the head is moved to one side
Clinical manifestation
• Brainstem Function Impairment
b. Decortication (flexion, adduction and
internal rotation of the upper extremities)
involvement above the midbrain
c. Decerebration (extension, adduction
and internal rotation of the arms)
involvement of brainstem.
- indicates poor prognosis, might
have CP arrest anytime
Clinical manifestation
• Alteration in:
a. Sensory Function (Agnosia-
unable to recognize and identify
objects, names etc.)
b. Motor Functions (Seizures)
c. Language and Speech
d. Bowel and Bladder function
(retention or incontinence)
Clinical manifestation
• ALERT!!!
Increased ICP is an emergency
case.
The Cerebral Cortex can tolerate
hypoxia for 4-6 minutes.
The Medulla Oblongata can
tolerate hypoxia only for 10 to 15
minutes.
Collaborative management
• Position – Semi-Fowler’s or Lateral
Position
• Head of Bed Elevation – 15 to 30
degrees, maximum of 45
degrees
- to promote drainage of CSF from
subarachnoid space of the brain to
the spinal cord
- this position also promotes
maximum lung expansion and
improves cerebral tissue
Collaborative management
• Adequate Oxygenation –
Mechanical Ventilation helps
promote acid-base balance (since
acidosis and alkalosis can cause
increase in ICP
• Safety – Prevent falls that may
result from altered level of
consciousness and seizure
• Rest- Physical and emotional
stress may further increase ICP
Collaborative management
• Avoid factors that increase ICP as
follows:
a. Nausea and Vomiting
b. Valsalva Maneuver (straining)
c. Over suctioning
d. Restraints Application
e. Rectal Examination
f. Enema
g. Bending or Stooping
Collaborative management
• If coughing and sneezing could
not be avoided, follow-through
with open mouth
• Control Hypertension since it
reduces cerebral tissue perfusion
• Restrict fluid intake – Limit fluid
intake to 1,200 to 1,500 L/day to
reduce CSF production
PHARMACOTHERAPY
1. MANNITOL- osmotic diuretic; it
reduces cerebral edema by increasing
urine output
Check urine output hourly
Check BP for potential hypotension
2. DECADRON (DEXAMETHASONE)
- a corticosteroid; it has anti-
inflammatory effect and reduces
cerebral edema
The ONLY corticosteroid that can
pass through BBB
PHARMACOTHERAPY
3. Anti-CONVULSANTS – to prevent
seizures
Dilantin (phenytoin)
Phenobarbital (sodium luminal)
Tegretol (carbamazepine)
4. ANTACIDS – to prevent GI irritation that
may be induced by Decadron
5. HISTAMINE H2 receptor antagonist
(Ranitidine) or PROTON PUMP
INHIBITOR(Pantoprazole)
- to prevent stress ulcers (cushing’s
PHARMACOTHERAPY
6. Anti-COAGULANTS - to prevent
thromboembolism
7. Dilantin (phenytoin )
! If given PO –after meals prevent GI
upset
If given IV prepare 10ml Normal Saline
(it crystallizes the vein)
- (5ml NS-Dilantin-5ml NS)
PHARMACOTHERAPY
7. Dilantin (phenytoin )
!!! SIDE EFFECTS
1. Gum Hyperplasia ( overgrowth of
gingival tissues/ swelling of gums)
- good oral care, use soft bristle
toothbrush, massage gums, regular dental
check-ups
2. Bone Marrow depression - leads to
Aplastic anemia a condition that occurs when
your body stops producing enough new blood
cells (weekly monitor CBC)
PHARMACOTHERAPY
Critical to Remember:
1. Opiates-narcotics (oxycodone)
and sedatives (barbiturates)
are contraindicated to the client
with Increased ICP; these drugs
caused Respiratory depression
that leads to acidosis.
2. Benzodiazepines (valium,
Ativan) are usually avoided
because of hypotension effect.
THANK YOU.
