You have not lived a perfect day unless youve done something for someone who will never

be able to repay you. Ruth Smeltzer

The skull is like a closed box with three essential volume components: Brain tissue 78% Blood 12% CSF 10%

Normal ICP
Normal ICP is the total pressure exerted by the three components within the skull: brain tissue, blood, and CSF.
Monro-Kellie Hypothesis states that because the bony skull cannot expand, when one of the three components expands, the other two must compensate by decreasing in volume for the total brain volume and pressure to remain constant.

Normal Compensatory Adaptations

Changing CSF volume by altering CSF absorption or production or by displacement of CSF into the spinal subarachnoid space.
Alterations in intracranial blood volume. Tissue brain volume compensates through distension of the dura or compression of brain tissue.

Normal ICP ranges from 0-15 mm Hg.

Cerebral Blood Flow

Cerebral Blood Flow (CBF) is the amount of blood in

milliliters passing through 10g of brain tissue in 1 minute. White matter Gray matter

Cerebral Blood Flow

Autoregulation is the automatic adjustment in the diameter of the cerebral vessels by the brain to maintain a constant blood flow during changes in arterial BP.
The lower limit of systemic arterial pressure at which autoregulation is effective in a normotensive person is a MAP of 50 mm Hg.

The upper limit of systemic arterial pressure at which autoregulation is effective in a normotensive person is a MAP of 150 mm Hg.
Mean Arterial Pressure (MAP) is the perfusion pressure felt by organs in the body.

Cerebral Perfusion Pressure (CPP)

CPP is the pressure needed to ensure blood flow to the brain. CPP= MAP- ICP
Cerebral vascular resistance, generated by the arterioles within the cranium, links CPP and blood as: CPP= Flow x Resistance

As the CPP decreases, auoregulation fails and CBF decreases.

Normal CPP is 70-100 mm Hg.

How does autoregulation regulate CBF and perfusion pressure?

Autoregulation regulate CBF and perfusion pressure primarily by adjusting the diameter of cerebral blood vessels and metabolic factors that impact ICP.

Pressure Changes
The relationship of pressure to volume is depicted in the pressurevolume curve.

Pressure Changes
Compliance is the expandability of the brain. It is represented as the volume increase for each unit increase in pressure.
Compliance= Volume/ Pressure

Stage 1- high compliance Stage 2-compliance begins to lessen Stage 3-significant reduction in compliance Stage 4-ICP rises to lethal levels with little increase in volume

Factors affecting blood flow

Increase in CO2 Relaxes smooth muscle Dilates cerebral vessels Decreases cerebrovascular resistance Increases CBF

Decrease in CO2 Constricts cerebral vessels Increases cerebrovascular resistance Decreases CBF

Factors affecting blood flow

Cerebral O2 tension below 50 mm Hg results in cerebral vascular dilation. This dilation decreases cerebral vascular resistance, increases CBF, and raises O2 tension.

Manifestations
Headache due to compression of other intracranial structures, such as the walls of arteries and veins and the cranial nerves.

Vomiting
Vomiting, usually not preceded by nausea, is related to pressure changes in the cranium.

Changes in Vital Signs

Changes in Vital Signs are caused by increasing pressure on the thalamus, hypothalamus, pons, and medulla. Cushings triad Systolic hypertension with a widening pulse pressure Bradycardia with a full and bounding pulse Altered respirations

Changes in Temperature
Changes in Temperature may be noted because of increased ICP impacting the hypothalamus.

Papilledema
It is an edematous optic disc seen on retinal examination.

Loss of motor function

Decorticate Posture Decerebrate Posture

consists of internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers as a result of interruption of voluntary motor tracts in the cerebral cortex.

May indicate more serious damage and results from disruption of motor fibers in the midbrain and brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar flexion.

Changes in LOC
Changes in LOC are a result of impaired CBF, which deprives the cells of the cerebral cortex and the reticular activating system (RAS) of oxygen.

Locked-in Syndrome
Due to infarction or hemorrhage of the pons that disrupts outgoing nerve tracts but spares the RAS. The client is alert and fully aware of the environment and has intact cognitive abiliies, but is unable to communicate through speech or movement because of blocked efferent pathways from the brain. In essence, the client is locked inside a paralyzed body while remaining conscious of self and environment.

Diagnostic Tests
History and PE
V/S, neurologic assessments, ICP measurements Skull test, chest, an spinal x-raystudies

CT Scan, MRI, PET, EEG angiography

Transcranial Doppler studies ECG CBC, ABGs, CSF anaysis

Medications
Osmotic diuretic (mannitol)
- Plasma expansion - Osmotic effect

Antiseizure drugs
Corticosteroids (for brain tumors, bacterial miningitis) Histamine (H2 receptor) antagonist to prevent GI

ulcers and bleeding

Ineffective Tissue Perfusion: Cerebral

Assess for and report manifestations of IICP every

15 minutes to I hour and PRN. Assessment areas include LOC, behavior, motor/sensory functions, pupillary size and reaction to light, V/S. Sudden changes in neurologic status often indicate deterioration. An elevated temperature with increased O2 consumption further increases intracranial pressure. Pupillary responses mirror the status of the midbrain and pons. Pressure on the brainstem may compromise the function of CN IX and X and protective mechanisms, such as the gag and cough reflexes.

 For the client on a mechanical ventilator: Maintain

patency of the airway: preoxygenate with 100% oxygen before suctioning to 10 seconds; suction gently. Preoxygenation helps maintain O2 levels during suctioning. Suctioning stimulates the gag reflex and Valsalva maneuver.
Monitor ABGs.

 Elevate head of the bed to 30 degrees or keep flat,

as prescribed; maintain the alignment of the head and neck to avoid hyperextension or exaggerated neck flexion; avoid prone position. Keeping the head of the bed elevated facilities venous drainage from the cerebrum. Obstruction of jugular veins can impede venous drainage from the brain.

 Monitor bladder distention and bowel

constipation. Administer stool softeners and use Crede technique( applying pressure on the suprapubic region with the fingers of one or both hands) to empty the bladder. If the Crede technique is not effective, evaluate the pros and cons of urinary catheterization if the bladder remains distended. Constipation and bladder distention increase intrathoracic or intra-abdominal pressure and place the client at risk for impaired venous drainage from the brain.

 If alert, assist in moving up in bed. Do not ask to

push with heels or arms or push against a footboard. Moving up in bed requires pushing. Helping the client to move prevents initiation of the Valsalva maneuver, which increases intracranial pressure. Plan nursing procedures so that activities are not clustered together; avoid turning the client, getting the client on a bedpan, or suctioning within the same time period. These can increase ICP.

 Provide a quiet environment, limiting noxious

stimuli. Avoid jarring the bed. Try to limit situations that cause emotional upset. These can cause an elevation of ICP. Maintain fluid limitations. Restricting fluids helps decrease cerebral edema by reducing total body water.

References
Black, J.et al. Medical-Surgical Nursing. Lemone, P. Medical-Surgical Nursing. Lewis, S.et al. Medical-Surgical Nursing.