 Welcome to Nursing School Explained and this video on increased intracranial pressure. If you haven't already done so, I highly recommend watching my other video that explains the relationship between intracranial pressure and cerebral profusion pressure and how it relates to mean arterial pressure so that you understand what the increased intracranial pressure means and also have a better understanding of why we do the nursing interventions that we do. So first of all, let's review here. So we have our brain that is made up of three different compartments inside that intracranial cavity inside our skull. We have brain matter, that's about 78%. We also have blood in our blood vessels that perfuse the brain which consists of about 12%. And then we have cerebral spinal fluid that just kind of regulates and cushions the brain, that's about 10% of those intracranial contents. Now when there is a bleed, for example, so now we have an injury here, a hematoma whether that's an epidural or a subdural hematoma, the blood compartment increases from the 12% to whatever it is to however much blood escapes from that blood vessel. Now there is less room available for the cerebral spinal fluid but more importantly the brain tissue and it gets displaced to the side. So now that blood takes up extra space here and pushes the brain tissue over towards the right side of the patient here. So the brain moves over which is also sometimes referred to as a midline shift that you might be able to see on a CT scan or an MRI result. So that midline that we usually have right in the middle here between the two cerebral hemispheres now moves over because it's being displaced by a space occupying lesion. Now what happens if this bleed extends and becomes really severe as in down here, the brain not only moves to the side but it also actually moves down towards the spinal cord, down the spinal canal. So now there is so much pressure here, the brain has nowhere else to go really because this blood percentage now is taking up so much space, the brain is moved over and down and when it's moved down it's called a brain herniation. Now recall that the brain stem and the medulla sit here at the base of the skull and they control the vital functions such as blood pressure, heart rate, respirations and temperature control. So all of these important functions that we often refer to as vital signs because they are vital to our survival and we'll look at how that relates to signs and symptoms here in a moment. So causes of increased intracranial pressure can be tumors for example where that brain tissue expands can be hemorrhages like I just discussed in the example over here. It can be due to infectious processes such as abscess formation and or inflammation and then conditions that also have increased cerebral spinal fluid would be a hydrocephalus for example that then needs to be drained the cerebral spinal fluid. So when we do have increased pressure in that intracranial compartment in our skull it leads to increased carbon dioxide which then leads to cerebral acidosis because the tissue perfusion is not happening the way that it should which means that it leads to impaired auto-regulation that's a term that I discussed in my other video and then systemic hypertension follows because now the brain is not being perfused so the body responds by increasing the systemic blood pressure to try and get more blood to flow to the brain to perfuse those important brain cells but we're already having too much of one of these compartments in here and that only increases more of that pressure which then leads to cerebral edema because these cells are swollen which leads to even more increase of that intracranial pressure and then if the tissue gets so compressed it leads to tissue hypoxia, acidosis and then eventually the herniation that we just discussed and by pushing on the respiratory center it can lead to respiratory arrest and basically death of the patient. So signs and symptoms as with anything that relates to our head will be a decreased level in consciousness so we have to be very judiciously assessing our patients with their glass caucomal scale and their neurological exams there will be change in vital signs and then there is a term called Cushing's triad which basically means that three things occur. Number one, increase the static blood pressure like which was discussed over here with a widening pulse pressure, number two, brain cardiac, number three, irregular respirations leading to in eventually low respiratory rate and then that respiratory arrest we just discussed. Now that can be also ocular signs and there might be ipsilateral pupil dilation which is why it's so important that we assess the patient's pupils and so recall that the cranial nerves cross over more towards the brain stem so if I now have a space occupying lesion more up high in my skull like we have in this example right here the cranial nerve that controls that the eye dilation on that side is on the same side as the brain lesion so ipsilateral means on the same side so the pupil would be dilated on the same side that I have that injury or that space occupying lesion and therefore I'm going to have an abnormal cranial nerve exam and so all the cranial nerves that control the eyes are going to be affected which are cranial nerves two, three, four and six so everything that has to do with pupil dilation as well as extraocular movement and the patient might complain of vision changes double vision blurry vision are very common here and then as you know for our neurologic exam we don't only assess cranial nerves but also peripheral motor and neurologic functions sensation and ability to move but if there are signs of increased intracranial pressure that motor function is going to decrease as well because now the brain is unable to communicate so that might lead to hemiparesis as well as decodicate and deseripate posturing and those are very indicative of something really wrong with the patient and this is basically a sign both of those signs mean that there is a shift occurring at least the shift may be even the hermitation and deseripate positioning or posturing is worse than the decodicate positioning the way I like to remember it is decodicate is to the core and deseripate means away from the core as you can see in these pictures right here so other signs and symptoms the patient might be complaining about if they are conscious our headache nausea and vomiting as we have so many signs when there is something going on in our brain diagnostic tests associated with increased cranial intracranial pressure might be CT scans or MRIs to see exactly what are what is the underlying issue electroencephalogram to measure the actual brain waves and to see how the brain is functioning as well as intracranial pressure monitoring they might get a transcranial Doppler ultrasound where they check the blood flow and then there is a device called the lycox device that is actually able to measure the brain tissue perfusion so how well the brain tissue is perfused now as far as treatments we have to basically if the patient's Glasgow coma scale is less than eight they will usually get what's called a ventricle ostomy and ventricle ostomy ventricles of the brain ostomy is an artificial opening so now what we have here again is our brain that has her that has shifted over to the side and we have this device that's inserted through the skull into the ventricles of the brain and then hooked up to a transducer and then the monitor will give us an output and see how the intracranial pressure is doing at the same time the same device allows us to maybe drain some cerebral spinal fluid because if we are able to maybe remove a little bit of that cerebral spinal fluid now we can decrease that pressure because now we have from those three compartments that we have here we have too much blood if we get rid of a little bit of the sea and sea asset the brain tissue has more room to expand and hopefully won't be so compressed and ischemic now over here again the ventricle ostomy we have the ability to remove cerebral spinal fluid as needed and as ordered and also we can measure the ICP with this device and then recall that the cerebral profusion pressure is calculated by the mean arterial pressure and we subtract the intracranial pressure now other treatment modalities that we also need to add here are medications that are super important in helping to reduce the cerebral edema and the medication that comes up here a lot is called mannitol which is an osmotic diuretic and so by the principle of osmosis mannitol removes fluid from the from the edematous cerebral tissue and pulls the fluid off into the intravascular space where the patient that is able to excrete very similar so hypertonic saline 3% sodium chloride works very similarly where if we give the patient a fluid that is more concentrated it causes that fluid shift again by the principle of osmosis and pulls that extra fluid from those cells so this is the cerebral cell and here we have the blood vessel and for both of the both of those it's very important that we check the fluid and electrolyte balance because specifically sodium and water content might get out of balance here and sodium is especially important and then if you recall whenever we give a hypertonic solution we have to ensure that we listen to the patient's lung sounds to make sure that this is not putting him into fluid volume overload and we would hear crackles if that occurs now if the cause of the increased intracranial pressure is a tumor or an abscess portico steroids are many times used for treatment and with those we have to make sure we check that blood sugar goes very frequently check the patient for any kind of infection that can occur with hospitalization as well as check them for GI bleeds by paying particular attention to maybe the NG tube that they have or their stools and then again monitor the fluid volume status and as well as administer H2 blockers and PPIs to reduce the gastric acidity to prevent those stress ulcers that could be forming and then because the cerebral tissue is now so irritable the patient many times will be put on prophylactic anti seizure medications we have to address their pain but this is a very delicate matter here because we don't want to over or under sedate the patient if we over sedate them we won't be able to really assess their neurologic status but if we under sedate them they might be altered they might be aggressive they might be agitated which then would even contribute to increasing the intracranial pressure even more so we have to be very judiciously administering any kind of pain and anti anxiety medication so that we can still assess the patient neurologically to see what their trends are doing and then a lot of times barbiturates are also used here which they just by administering administration of them if they decrease cerebral metabolism and therefore decrease ICP the nursing care besides everything here in green that we've already discussed we need to clearly assess the patient's vital signs and neural checks frequently especially the eyes and their motor function their posturing like we just discussed with deseribrate and decodicate positioning because we know if the brain starts to shift or herniate it's going to affect the basic vital functions and vital signs and the easiest or quickest way to assess this is by doing that eye and motor exam to see what is changing and then certainly we have to monitor the ICP the intracranial pressure by the device of the matriculostomy and then in terms of their respiratory function so this patient will be intubated and we have to limit suctioning keep the head of the bed at 30 degrees and also insert an NG to for gastric deflation unless there is contraindication and so the respiratory function is very important here because recall that the brain depends on certain things and CO2 build up so acidosis can be detrimental to the brain health so we have to make sure that we allow the patient's respiratory function to be working properly and that their chest can expand as well as that their stomach is deflated so it's not putting pressure on the lungs which then can increase the pressure in their intraceracic cavity which then can increase leading to increase in pressure in the cerebral cavity as well and then body positioning in general for all those reasons I just discussed is important we want to keep the head at midline because recall that we have the carotid arteries and the jugular veins that profuse the brain and drain the brain so if we even just turn the head over to the side it can kind of occlude that pressure or cause problems with that cerebral artery regulation and therefore increase intracranial pressure we want to avoid neck flexion for the same reasons we want to turn the patient very slowly and carefully with assistance of probably many healthcare providers to ensure that they stay nice and calm and that we can maintain the posture and even when we when we turn them we want to avoid coughing, straining and any kind of valsalva maneuver for the same reasons because whenever you cough that that intraceracic pressure increases which therefore can increase the intracranial pressure straining so we want to make sure that they will have a urinary catheter so that bladder is not descended and that they are not straining to have a bowel movement because again straining and activation of the valsalva maneuver can increase the intracranial pressure which again could lead to increased intracranial pressure and we want to avoid hip flexion for the same reasons and other things that are important is protect the patient from injury now whenever there are patients with head injuries they might be agitated they might become combative and so in order to keep them safe not only from you know removing maybe the and the tracheal tube but pulling on other lines and devices but also to protect them from injury because of their combative status as well as they might need seizure precautions on and side rail padding and then we have to address the psychosocial needs. Head injuries can be anxiety inducing if the patient is even aware of it because due to cerebral edema they might be altered but also we need to provide them with short and simple explanations because their brain is now not able to function normally because of this increased intracranial pressure so we have to keep it very short and simple so that they can actually follow our commands. So thank you for watching this video on increased intracranial pressure and how it relates to cerebral perfusion and head injuries recall that it can that can be several different causes for it anything that is a space occupying lesion in that intracranial cavity such as tumors, abscesses, bleeds and cerebral spinal fluid increase such as hypercephalus. Thanks for watching Nursing School Explained. See you soon.