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Caring for Clients with Central

and PeripheralNervous System


Disorders
Frengki Apryanto, S.Kep.,
Ners., M.Kep
Medical/surgical nursing X:
Neurobehavior

Learning Objectives
On completion of this chapter, you will
be able to:
Discuss at least four signs and
symptoms and nursing care of the
client with increased intracranial
pressure

INCREASED INTRACRANIAL
PRESSURE

Inside the cranium, there is:


(1) brain tissue,
(2) blood, and
(3) cerebrospinal fluid (CSF).

The brain represents 84% of the cranial


contents; the blood within the cranium
contributes 4% of the total; the CSF provides
the remaining 12%
If one or more of these increases significantly
without a decrease in either of the other two,
intracranial pressure (ICP) becomes elevated.

Pathophysiology and
Etiology
Under normal circumstances, autoregulatory
mechanisms keep brain tissue perfused with
adequate oxygen and glucose.
Dilation or constriction of cerebral blood vessels
in response to changes in blood pressure, blood
oxygen levels, and blood pH maintains constant
and consistent tissue perfusion.

For example, increased PaCO2


(carbon dioxide level in the blood),
decreased blood pH, or decreased
PaO2 (oxygen level in the blood)
causes cerebral blood vessels to
dilate.

Ideally, ICP remains at 15 mmHg or


below to ensure normal cerebral
perfusion pressure (CPP) of 70 to 100
mm Hg

Many conditions, including brain


tumors,
swelling or bleeding within the brain
from head trauma, and infectious
and inflammatory disorders of the
brain (e.g., meningitis, encephalitis),
cause increased ICP.

When the intracranial volume (and therefore ICP )


begins to increase, some initial compensation
occurs.

CSF production may decrease, or it may displace


at a greater rate in to venous circulation

However, as ICP continues to rise,


vascular autoregulatory mechanisms can become
compromised and fail.

If increased ICP continue s to be


unrecognized or untreated , the contents
of the cranium are compressed further.
Unrelieved pressure causes brain tissue
to herniate or shift from normal locations
intracranially and extracranially (Fig.1).

FIGURE 1. Major types of intracranial herniations. (1) Cingulate


herniation. (2) Central transtentorial herniation. (3) Uncal
herniation.
(4) Infratentorial herniation of cerebral tonsils.

The foramen magnum, the opening in


the lower part of the skull through which
the upper part of the spinal cord connects
with the brain, provides the only
extracranial exit for brain tissue.
If the brain stem herniates through the
foramen magnum, respiration, heart rate,
blood pressure (BP), and the functions of
descending and ascending nerve fibers are
affected.

As increased ICP progresses, the


consequences include impaired
cellular activity, temporary or
permanent neurologic dysfunction, or
death.

Assessment Findings

Signs and Symptoms


The signs and symptoms of increased ICP
(Box 37-1) can develop rapidly or slowly.
Decreasing level of consciousness (LOC) is
one of the earliest signs of increased ICP.
Clients may slip from alert and oriented to
lethargic, stuporous, semicomatose, and,
finally, comatose .
Confusion, restlessness, and periodic
disorientation often accompany
decreasing LOC.

Headache is another symptom of


increased ICP. Headache, which is more
severe in the morning, increases with
activities that elevate ICP, such as
coughing, sneezing (bersin), or straining
at stool.
Rest or elevation of the head relieves the
pain.

Changes in ICP also influence vital


signs. Body temperature may rise or
fall depending on the etiology of the
increased ICP or because of its effect
on the temperature-regulating
center.

Medical and Surgical


Management
Immediate treatment aims at decreasing ICP by
relieving the cause if possible.
The goals are to maintain BP, prevent hypoxia, and
ensure cerebral perfusion.
To maintain cerebral tissue perfusion and BP, the
physician administers isotonic normal saline, lactated
Ringers, or hypertonic (3%) saline solutions.
Hypotonic solutions and solutions containing glucose
increase ICP.

Providing

supplemental oxygen or
mechanical ventilation to keep the
SaO2 at 95% and the PaCO2
between 35 and 45 mm Hg prevents
hypoxia.
The clients head is maintained in
midline at 30 of elevation to promote
venous drainage of blood and CSF.

The physician can control the clients


seizures, which elevate ICP, by
administering diazepam (Valium) and
fosphenytoin (Cerebyx).

Pharmachologic considerations
Narcotic analgesics depress the
respiratory center and raise CSF
pressure.
Their use is contraindicated in clients
with
head trauma or increased ICP, unless
administration is an absolute
necessity

FIGURE -2. Techniques for monitoring intracranial pressure (ICP).


(A) A fiberoptic, transducer-tipped device placed in the ventricle,
(B) subarachnoid screw, (C) intraparenchymal sensor, or
(D) subdural bolt. These devices connect to a pressure transducer
and display system.

Nursing Management
NURSING CARE PLAN: The Client With
Increased Intracranial Pressure

Assessment
Gather from client or a witness,
paramedic, or emergency medical
technician the history of
circumstances surrounding the
altered neurologic state. Also gather
past medical history, concurrent
health problems being treated,
current medications, and allergy
history

Assess level of consciousness (LOC)


and vital signs.
Assist with a head-to-toe physical
examination
Perform complete neurologic
assessments, including the Glasgow
Coma Scale (GCS) . Repeat these
assessments every 30 to 60 minutes.

Measure current and daily weights


and intake and output measurements.
Study laboratory findings such as
serum electrolyte and arterial blood
gas levels.
Evaluate the presence of bowel
sounds and bowel elimination.
Note evidence of any seizures.

Thank you

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