Introduction
Elevated Intracranial Pressure (ICP) most commonly occurs in head injury, hydrocephalus, space-occupying lesion, encephalopathy, and cerebral edema. It can lead to death or devastating neurological damage either by decreasing cerebral tissue perfusion pressure (CPP) and causing cerebral ischemia or by compressing and causing herniation of the brainstem or other vital structures.
An elevated ICP is measurable both clinically and quantitatively. Continuous ICP monitoring is important for assessing the efficacy of therapeutic measures and for evaluating the evolution of brain injury.
Definition
ICP monitoring is a technique used to monitor the ICP to evaluate intracranial disorders.
Purposes
- To measure CPP.
- To plan a treatment to reduce ICP and volume.
- To evaluate and improve the prognosis
Indications
- Intracerebral hemorrhage.
- Cerebral edema.
- Head injury.
- Postcraniotomy.
- Space-occupying lesions such as subdural and epidural hematomas, abscess, tumors, or aneurysms that occlude the CSF.
- Reye syndrome patients who develop coma, posturing, and abnormal responses to noxious stimuli.
- Encephalopathy from hypertensive crisis, lead ingestion, or liver failure.
- Meningitis or encephalitis that causes malabsorption of CSF.
Normal Values
The ICP is graded as follows:
- Normal: 5-15 mmHg.
- Mild elevation: 16-20 mmHg.
- Moderate elevation: 21-30 mmHg.
- Severe elevation: 31-40 mmHg.
- Very severe: >40 mmHg.
Types of ICP Monitoring Systems
There are multiple devices for monitoring ICP.
- External Transducer Systems
Three types of external transducer systems are as follows: - Intraventricular catheter (IVC).
- Subarachnoid bolt or screw.
- Subdural, epidural, or intraparenchymal catheters.
- Internal Transducer Systems
- Fiber-optic transducer-tipped catheter.
The current method of choice and the gold standard is ventriculostomy using an IVC.
Assessment
Assess the following
- Level of consciousness.
- Changes in vital signs.
- Rise in BP or widened pulse pressure.
- Pulse changes with bradycardia to tachycardia as ICP rise.
- Pupillary changes.
- Changes in pupil size: Fixed and dilated for midbrain involvement: pinpoint for pontine involvement.
- Respiratory irregularities.
- Tachypnea.
- Slowing of rate with lengthening periods of apnea.
- Cheyne-Stoke respiration or Kussmaul respiration.
- Central neurogenic hyperventilation.
- Apneustic breathing and ataxic breathing.
- Extraocular changes.
- Inability to abduct or adduct.
- Alteration in vision.
- Spontaneous eye movement.
- Nystagmus or vertical gaze.
- Oculovestibular reflex.
- Other changes.
- Headache, vomiting.
- Papilledema.
- Subtle changes-restlessness, headache, forced breathing.
- Motor and sensory dysfunctions-proximal muscle weakness.
- Contralateral hemiparesis.
- Speech impairment.
Articles
| Articles | Purpose |
| Sterile gloves, mask, and surgical cap | To prevent cross-infection. |
| Monitoring system (intraventricular, subarachnoid, or epidural) | To monitor ICP. |
| IV pole or stand | To mount the system. |
| IV high-pressure tubing | To monitor ICP. |
| Burr hole tray | For insertion of catheter. |
| Local anesthetics | To relieve pain. |
| Normal saline | For irrigation. |
| Vital signs record | To document baseline and changes. |
Procedure
| Nursing Action | Rationale | |
| 1. | Explain the need for extensive continuous assessment and appropriate nursing intervention to the family and the patient if possible. | Decreases anxiety and allows the patient and family to have a sense of control. |
| 2. | Gather and assemble equipment. Flush lines with ordered solution according to manufacturer’s directions. | Availability of articles enhances success of the procedure. |
| 3. | Calibrate equipment according to instructions. | Accurate interpretation of ICP depends on appropriate baseline function. |
| 4. | Perform neurological assessment. | To determine changes and guide therapy. |
| 5. | Administer light sedation or analgesia as per order if agitation is present. | To avoid injury secondary to excessive movement. |
| 6. | Position head of the patient at 30°. | Facilitates venous drainage, decreases intracranial volume, and prevents collapse of ventricles if ventricular placement, but it can also lead to decreased cerebral perfusion. |
| 7. | Don sterile gloves, mask, and surgical cap. | Reduces risk of transmission of microorganisms. |
| 8. | Shave and cleanse the appropriate site. | Removes bacteria from the site and reduces risk of transmission. |
| 9. | Establish the sterile field. | Reduces risk of infection. |
| 10. | Assist with burr hole and placement of catheter and intracranial pressure monitoring systems. | Direct monitoring of ICP allows for early detection and management of complications. |
| 11. | Connect monitoring catheter to transducer monitoring equipment according to directions. | Allows for conduction of ICP and CPP to the interpretive component of the system. |
| 12. | Observe numeric readings and wave patterns; adjust characteristics to obtain optimal visual reading. | Changes in baseline recording indicate alterations in ICP or problems with mechanics of monitoring system. |
| 13. | Cover the catheter insertion site with a sterile dressing. Observe for possible CSF drainage depending on the placement of the catheter. | The skull and the meninges have been penetrated leaving the risk of infection. |
| 14. | Adjust alarm system according to ordered parameters. | To indicate nurse about ongoing change. |
| 15. | Frequently assess the patient and the system to ascertain the neurological status, assessing ICP and CPP, and patency of the system. | Manipulation of the system may inadvertently close the system, leaving the patient without benefit of monitoring. |
| 16. | Irrigate the system using sterile technique according to policy or as needed to maintain patency. | Irrigation helps to maintain patency of system. |
| 17. | Report dampened waveforms, and have 1 mL of normal saline for irrigation if indicated. | The tip of the catheter may have to be migrated against the ventricular wall or cerebral tissue depending on location. |
| 18. | Assess head dressing for CSF drainage. Change dressing according to facility policy. | Because of its high glucose content, CSF is the excellent medium for bacterial growth. |
| 19. | Adjust the height of the transducer of the system to the level of the patient’s ventricles (inner canthus of eye and tip of ear) with every position change for accurate readings and per orders. | Position of the transducer influences accuracy due to fluid gradient pressures. |
| 20. | Monitor the patient for any complications such as infection, intracerebral hemorrhage, CSF leak, mechanical equipment failure, CSF overdrainage, hematoma, bleeding, brain herniation, damage to the brain tissue, infection. | To facilitate early management. |
| 21. | Document the ICP level, date and time, amount of CSF collected, color, etc., condition of the patient, neurological assessment findings, vital signs, and any complication. | To facilitate appropriate planning of postprocedural care. |
Special Considerations
- In non-traumatic cases (e.g., stroke, meningitis, hepatic encephalopathy), decisions should be individualized based on clinical deterioration or imaging.
- Intraventricular catheters offer the most accurate readings and allow CSF drainage but carry higher infection risk.
- Subarachnoid bolts and intraparenchymal monitors are less invasive but may not allow CSF drainage.
- Choose the device based on ventricle size, presence of hemorrhage, and institutional protocols.
- Use strict aseptic technique during insertion and maintenance.
- Monitor for signs of CNS infection, especially with long-term use.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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