Introduction
Patients have different conditions and have different ways of being treated. Patients whose conditions are grave and might die any moment if neglected, need utmost medical intervention and attention. This research will focuses on patients with increased Intracranial Pressure (ICP). Based from the case given, terminologies and concepts of nursing intervention on patients with ICP will be discussed. Then pathophysiology of ICP will be explained so that there is an understanding of the usual protocol done with patients suffering ICP. An analysis of the case in the light of pathophysiology will be explicated, focusing on suggestions on how to apply the pathophysiology on the patient’s case as part of nursing care. Then a conclusion on the importance of nursing care will be drawn on its impact for evidence-based nursing practice.
Literature Overview
“Intracranial Pressure (ICP) is defined as the measure of cerebrospinal fluid pressure within the cranium.” Normal ICP ranges from 0 – 15 mm Hg. A resting ICP value greater than 20 mm Hg is defined as intracranial hypertension and may be acute or chronic in nature. Increased ICP can result in irreversible damage to the cranial contents by impairing blood flow and eventually cause death if left untreated. (Ocreto, N. 2008.)
he case starts with a scene of a 50-year old male, named Mr. Khan. He was found at the bottom of the stairs by his wife and daughter, lying face down. Khan’s wife noticed blood trickling from his nose and called the ambulance. In A/E, a CT-scan revealed a subarachnoid bleed. The nurse assigned to look after Khan reported a GCS score of 3, therefore Khan was intubated and ventilated with his head elevated to 30 degrees. Cardiovascular and neurological monitoring commenced, together with fluid management and intravenous crystalloids. He was sedated on propofol and morphine to facilitate ventilation and avoid a rise in intracranial pressure.
Two hours later, Khan’s heart rate dropped to 38 beats per minute and his blood pressure rose to 180/100. His right pupil was enlarged to size 6 and was not reacting to light. His sedation and analgesia were increased and Khan’s wife and daughter were informed of his poor condition. Unfortunately within a short while, Khan’s left pupil also became fixed and dilated. A diagnosis of coning and brain stem compromise was made. Brain stem tests were organised and a diagnosis of brain stem death made. The family were approached regarding organ donation.
Analysis
The CT-scan enabled to determine that there is a subarachnoid bleed in Mr. Khan’s head. This raised the fact that there is an increase in Intracranial Pressure needed to be controlled immediately. The ICP is determined by: the rate of cerebrospinal fluid production (which is 0.3 to 0.4 cc per minute); the rate of cerebrospinal reabsorption; and the pressure exerted in the sagittal sinus as the cerebrospinal fluid returns to the heart via the external veins. The difference between the arterial blood pressure entering the brain and the pressure of venous blood exiting the brain is called the cerebral perfusion pressure (CPP). “This is the amount of pressure required to force the blood upward into the brain overcoming gravitational forces” (Ocreto, N. 2008). Normal value is 60 to 100 mm Hg.
At levels less than 60 mm Hg, hypoperfusion of the brain occurs with irreversible ischemia and infarction occurring at less than 40 mm Hg. Brain death occurs when the CPP is 0 to 40mm Hg. If there is an increase in ICP, there will be a decrease in CPP and visa versa, because CPP is always inversely proportional to ICP. Because of this, an increase in ICP will cause a decrease in circulating blood volume to the brain resulting in increasing carbon dioxide and decreased oxygenation to the brain causing hypoxia. Hypoxia is lack of enough oxygen in the blood, therefore it can increase carbon dioxide which leads to hypercarbia. It was mentioned that a nurse performed the Glasgow Coma Scale (GCS ) assessment on Mr. Khan and found out that he has a score of only 3; and patients with GCS scores of 3 to 8 are usually said to be in a coma. To give a good picture of how GCS was derived, the total score came from the sum of the scores in three categories as shown in the table below:
The Glasgow Coma Scale is used to categorize coma patients’ level of consciousness (LOC). In the GSC procedure, the measurement of the cerebrospinal fluid pressure or ICP is important. To explain its importance, normally, the total volume of the cranial contents (brain, tissue, blood and cerebrospinal fluid) should equal to 1700 to 1900 cc. This volume remains constant to assure stability of cerebral functioning. The “Monro-Kellie hypothesis” supports the idea that “if any one of the three cranial contents is either increased or decreased in volume, the other two components will increase or decrease inversely to maintain the consistent equal volume of 1700 to 1900 cc. If the compensation process of the other two components is lost or impaired, ICP will increase. As the pressure continues to increase the reticular activating system (RAS) and cranial nerves III, IV and VI are pressed on leading to the outward symptomatology seen.” (Ocreto, N. 2008).
This is the reason why it is a necessary procedure to monitor cardiovascular and neurological activity in order to maintain a normal ICP. So, in order to maintain normal fluid flow, all necessary means to avoid sudden influx of fluid into the brain should be strictly observed. So when Mr. Khan’s blood pressure rose to 180/110, his sedation and analgesia was increased to reduce brain activity, thus reducing cerebral blood flow. Factors that can increase cerebral blood flow are: increase in blood pressure, hypercapnia with associated hypooxygenation, and medications taken that can cause vasolidation of the nerves. If the compensatory mechanisms of the brain are impaired, all this extra blood creates increased intracranial pressure as brain tissue cannot decrease. Increases in intrathoracic pressure is normally benign, but as thoracic pressure increases, intracerebral pressure increases but returns to normal after the activity has stopped. So to avoid increase in pressure, suctioning, coughing, vomiting should be prohibited.
Cerebrospinal fluid accounts for approximately 12% of the cranial vault contents. Inappropriate positioning of the head or neck can lead to impaired drainage of the venous and cerebrospinal fluid systems. This results in extra amounts of fluid remaining in the cerebral vasculature and increased ICP. As with cerebral edema, any change in level of consciousness is the earliest and first symptom to be seen. It should be monitored closely and reported to the physician immediately. It may include restlessness, agitation, mild confusion, personality changes, and decreasing Glasgow Coma Score. As the pressure progresses, it will start to affect the reticular activating system and cranial nerves. By the time these changes are noted, the ICP will already be dangerously elevated.
Noted early changes include headaches (usually early morning with noted vomiting), slowed or slurred speech, memory impairment, decreased hand grasp or paresis, decreased response to touch or pinprick, pupils will be delayed or sluggish to react to light (shape of it will become ovoid or they will become unequal), vision may become blurred with decreased visual acuity, and seizure activity may or may not be present. Because of the danger of imminent death of patients suffering with increasing intracranial pressure, utmost nursing care should be properly observed. Patients displaying late symptoms require immediate intervention otherwise cerebral herniation will be imminent. Late changes include: decreased level of consciousness with difficulty to arouse and further decrease in the GCS; pupils will become unilaterally enlarged progressing to fixed and dilated which happened to Mr. Khan, and eventually becoming bilaterally fixed and dilated with noted papilledema; the patient will decorticate or decerebrate posturing to flaccidity; speech may be absent with only moaning; respiration will be irregular advancing to neurogenic hyperventilation and respiratory arrest; loss of corneal and gag reflexes; and shows abnormal reflexes such as positive Babinski reflex.
To treat patients with ICP, nurses should maintain the patients head midline to facilitate blood flow; maintain the head of the bed at 30 to 45 degress to facilitate venous drainage; avoid activities that can increase ICP such as suctioning or gaging; treat hyperthermia as it increases the metabolic needs of the brain and decrease environmental stimuli which can increase ICP; maintain fluid balance via accurate I & O so as to prevent overhydration and may lead to edema; monitor electrolytes since patients are prone to hypernatremia, hypoglycemia, and hypokalemia with diuretic usage; monitor hyperventilation to maintain carbon dioxide at 25 – 35 mm Hg to prevent vasolidation; and the use of lidocaine prior to suctioning to decrease gag reflex.
And to show extra care for patients with ICP, the nurse should dim all lights so that the patients with ICP don’t suffer with too much bright lights; nurses should speak softly; nurses should touch gently and only when the patient needs it; all interventions should be spaced and to limit noxious stimuli such as suctioning to only as needed. That’s why in the case of Mr. Khan, the nurse showed care for him because they’ve done the head elevation to decrease pressure on the head and they’ve done measures to prevent him from gaging due to suctioning; they’ve given him crystalloids to aid it. As part of nursing ethics, the nurses informed Mr. Khan’s family about his failing health so as to condition them that anytime he might pass away, and that if they wish they can have him for organ donation.
Conclusion
Nursing management on treating patients with ICP greatly affects the process of recovery, even though the patient might not likely survive. The recorded observations of all the factors to control ICP is efficient in evidence-based research in nursing. Without proper record procedure of the patient’s condition with ICP, then fluid control going to the brain will be left unmonitored and the patient wouldn’t have likely survived that long. These recorded observations are still essential to the development of nursing care and practice and can be used as evidence for further research and studies on the treatment of patients with ICP.