Increased Intracranial Pressure (ICP): What Nurses Need to Know

The skull is stuffed with brain tissue, blood, and cerebrospinal fluid (CSF). Cerebral autoregulation allows these components to regulate to one another to keep up blood flow through the brain. Intracranial pressure (ICP) is often lower than or equal to fifteen mm Hg in adults. Pathological intracranial hypertension occurs when ICP is bigger than or equal to twenty mm Hg (Smith & Amin-Hanjani, 2024).

The development of increased intracranial pressure (ICP) will be acute or chronic. It is a typical clinical problem in neurology or neurosurgical departments. Many diseases or injuries may end up in lack of cerebral autoregulation and result in increased ICP, including traumatic brain injury, large acute ischemic stroke, intracerebral hemorrhage, aneurysms, brain tumors, and infections equivalent to abscess or severe meningitis.

Acute, sustained elevations in ICP will end in decreased cerebral perfusion pressure (CPP) and cause cerebral ischemia. Treatment of patients with elevated ICP requires rapid recognition, monitoring of ICP and CPP, and interventions aimed toward lowering ICP and optimizing blood pressure.

Nursing interventions

If a patient is suspected of getting increased ICP, immediate interventions should include securing the airway, maintaining adequate oxygenation and ventilation, and providing circulatory support as needed (Tran et al., 2023). Interventions to scale back or stabilize ICP include elevating the top of the bed to thirty degrees, maintaining a neutral neck position, maintaining normal body temperature, and stopping volume overload. The patient have to be stabilized before transfer to radiology for brain imaging. Computed tomography (CT) is essentially the most effective test to substantiate the diagnosis of increased ICP and determine its cause. In many cases, invasive ICP monitoring is required to guide medical and nursing interventions.

Patients requiring ICP monitoring must be cared for by trained neurologic critical care nurses who’re competent in neurological assessment and management of the monitoring device. Assessment of the patient should include hourly monitoring for signs and symptoms related to changes in ICP, or more steadily if the clinical situation requires it. The physician must be notified immediately if the ICP exceeds established parameters. If no parameter is specified, the physician must be notified if the ICP is bigger than 20 mm Hg or the CPP is outside the range of fifty–70 mm Hg (Smith & Amin-Hanjani, 2024).

The two commonest ICP monitoring devices are the intraparenchymal monitor and the intraventricular monitor using a ventriculostomy or external ventricular drain (EVD). The EVD is preferred since the catheter can even drain cerebrospinal fluid and thus reduce intracranial pressure. For detailed information on nursing look after patients with ICP monitoring devices, check with American Association of Neurological Nurses (AANN) Clinical Review: Monitoring Intracranial Pressure.

Acute intracranial hypertension

Acute intracranial hypertension (AIH) is a clinical syndrome through which homeostatic mechanisms are overwhelmed, causing a rapid increase in ICP. AIH is a medical emergency that requires immediate treatment to forestall irreversible neurological damage or death. Patients in danger for AIH must be monitored in an intensive care setting. AIH will be treated with a wide range of medical and surgical interventions:

• using external ventricular drainage or lumbar drainage.
• involves removing a part of the skull to lower ICP.
• to regulate pain, agitation and excessive muscle activity (e.g. brought on by delirium).
• with isotonic fluids. If there aren’t any signs of dehydration or fluid overload, intravenous saline fluids at 50–75 mL/h could also be initiated. The rate of administration could also be adjusted based on serum sodium concentration, osmolality, diuresis, and physical assessment (Maiese, 2019).
• to scale back intracranial volume and maintain serum osmolality between 295 and 320 mOsm/kg. Fluid and electrolyte balance must be closely monitored during either therapy (Smith & Amin-Hanjani, 2024).
• when hypertension is severe (greater than 180/95 mm Hg). Mean arterial pressure have to be high enough to keep up CPP even with a rise in ICP (Maiese, 2019). Hypotension must be treated promptly to avoid cerebral ischemia.
• They are only effective in cases of vasogenic edema (brought on by disruption of the blood-brain barrier) brought on by brain tumors and sometimes abscesses.
• causes hypocapnia, which causes blood vessels to constrict, thereby reducing blood flow to the brain. Hyperventilation to moderate levels (PaCO₂ = 25-35) is mostly considered a short-term temporary measure to scale back ICP. Extreme hyperventilation (PaCO₂ Pressure below 25 mm Hg must be avoided (Smith & Amin-Hanjani, 2024).

More about nursing care

The neurology intensive care nurse should have extensive knowledge of the physiology of the brain and the way it changes as patients deteriorate or get well. Nursing measures—including the ABCs of managing increased intracranial pressure—are focused on assessing changes within the neurologic examination, preserving cerebral blood flow by optimizing CPP, and protecting the brain from secondary injury (Hussein, 2017). Neurology intensive care nurses are expected to oversee patient care by adjusting ventilator settings, medications, fluids, dietary support, and therapeutic devices to maintain the patient stable in the course of the recovery process. Patients with increased ICP might be cared for by a multidisciplinary team that features physicians of varied specialties, respiratory therapists, dietitians, and physical and occupational therapists. Neurology nurses are care coordinators and advocates for patient safety.

In addition, the nurse provides family education and emotional support in a high-tech environment. It is essential for the nurse to elucidate the impact of the environment and external stimuli on the patient’s ICP and to interact the family in plans to regulate stimuli to reduce elevated ICP readings.

Prompt recognition and treatment of patients with increased ICP requires knowledge of the patient population in danger and the signs and symptoms of increased ICP. AIH resulting from a rapid increase in intracranial pressure is a medical emergency requiring immediate stabilization of the airway, respiration, and circulation, followed by immediate brain imaging to substantiate and diagnose the underlying etiology. Monitoring ICP is the cornerstone of treatment. The neurology intensive care nurse provides a peaceful, quiet environment, vigilant monitoring, and interventions to optimize cerebral blood flow and stop complications.

Glasgow Structured Approach to Assessment of the Glasgow Coma Scale. Royal College of Physicians and Surgeons of Glasgow. Retrieved from: https://www.glasgowcomascale.org/what-is-gcs/

Hussein, M., Zettel, S., Suykens, A. (2017). ABC of coping with increased intracranial pressure. , 6-14.

Levine, W., Allain, R., Alston, T., Dunn, P., Kwo, J., Rosow, C. (2010). Anesthesia in neurosurgery. 389-408.

Maiese, K. (2019). Brain Herniation. The Merck Manual Professional Edition. Retrieved from: https://www.merckmanuals.com/professional/neurologic-disorders/coma-and-impaired-consciousness/brain-herniation

Smith, ER and Amin-Hanjani, S. (May 29, 2024) Evaluation and treatment of elevated intracranial pressure in adults. https://www.uptodate.com/contents/evaluation-and-treatment-of-intracranial-pressure-in-adults

Tran, D., Supa, E., Young, A., Ricke, D., and Censullo, J. (2023). Evidence-based clinical review: intracranial monitoring. AANN clinical practice guidelines. https://aann.org/uploads/Publications/CPGs/AANN23_ICP_EBCR_FINAL.pdf