Transcript Brain shift and herniation

신경외과 강의 과정
두개강 내압
아주대학교병원
윤 수한
Department of Nursing (UCSF)
Training Programs
• Acute Care Training Program (ACTP)
• Adult Critical Care Training Program (CCTP)
• Pediatric Critical Care / Pediatric Acute Care
Training Program (PCCTP/PACTP)
• Emergency Department Training Program
(EDTP)
내용
1.
두개강 내압에 관여하는 두개강의 구조적 특징
2.
두개강내 용적과 압력과의 관계
3.
두개강 내압과 뇌혈류와의 관계
4.
정상 두개강 내압의 범위와 체위에 따른 변화
5.
두개강 내압의 측정방법과 그 장단점
6.
두개강 내압항진에 의한 뇌기능장애와 생체징후에 대한 영향
7.
두개강 내압항진의 치료
8.
두개강 내압 항진에 의한 뇌탈출
Fall 2001 UNIVERSITY OF TEXAS SAN ANTONIO SCHOOL OF NURSING
OBJECTIVES: Neuroscience Nursing
1)
Explain the Monro-Kellie Hypothesis.
2)
Interpret a Volume-Pressure Curve.
3)
State the normal intracranial pressure.
4)
Define compliance.
5)
Relate the concepts of cerebral blood flow and cerebral
perfusion pressure to clinical appearance.
6)
Distinguish between three types of cerebral edema.
7)
Describe the clinical signs associated with an increase in
intracranial pressure.
8)
Differentiate between the types of cerebral herniation.
9)
Discuss the nursing care of increased intracranial pressure, with
particular emphasis on drug therapy.
10)
Review four types of intracranial monitoring systems.
11)
Develop a comprehensive nursing care plan for the patient with
increased intracranial pressure.
두개강내 구조물
1. 두개강내 혈액량
• 호흡저하
PaCO2 증가 또는 PaO2 감소
뇌혈관 확장
• 정맥 폐색
정맥 울혈 ( valve가 없음)
뇌척수액 분비와 흡수
• 분비
– choroid plexus, ependymal
cells of ventricle
• 흡수
– arachnoid villi, blood vessels,
cranial nerves via lymphatic
channel
뇌척수액 순환
두개강내 용적
• 뇌척수액 10 %
• 두개강내 혈액 4-10 %
뇌부종
저산소증, CO
종양
Vasogenic edema
Cytotoxic Edema
Hydrocephalic (Interstitial) Edema
Monroe Kellie의 가설
두개강내
뇌척수액 두개골
두개골은 뇌, 혈액, 그리고
뇌척수액으로 이루어진 한정된
공간이므로, 이들 중 한가지의
용적증가는 두개강내 압력을
척수강
증가시키고 나머지 두가지의 용적의
감소를 초래한다.
두개강 내압
(mmHg)
비정상적 종괴 병변
(공간점유 병변)
• 종양, 혈액  뇌부종
• Pus, etc  정상
뇌구조의 이동
두개강 내압항진
용적
적응의 한계
압력
동맥
• 적응 한계점에
뇌척수액
이르면 (두개강
정맥
내압 위기),
적은 용적증가에
의해서 높은 압력
상승이 일어난다.
변이 용적
뇌압증가의 역동적 변화
병변크기 증가
국소적 압력증가
국소적 뇌부종
국소적 뇌 이동
뇌척수액 통로 폐색
수두증
미만성 뇌압 증가
중뇌 및 소뇌 탈출
전반적 뇌 저산소증
뇌간 출혈 및 허혈
뇌혈류 단절
사망
뇌혈류 변화
(blood pressure, PaCO2 and PaO2)
뇌혈류
ml/100mg/min
압력
자기조절(Autoregulation)
1) 혈압성 자기조절 (Pressure autoregulation)
2) 대사성 자기조절 (Metabolic autoregulation)
① 저산소증 (Hypoxemia)
② 고이산화탄소증 (Hypercarbia)
③ 산도 (pH)
혈압성 자기조절 (Pressure
autoregulation)
전신동맥압이 50 ~ 160
mmHg 일 경우에
뇌혈류의 혈압성
자기조절기능이
가능하다.
대사성 자기조절 (Metabolic
autoregulation)
뇌에서 대사정도와 혈류의 양은 정확히 비례한다.
기전 :
1)
저산소증 (Hypoxia)
2)
고이산화탄소증 (Hypercarbia)
3)
산도 (pH -- ECF lactic acidosis)
4)
Increased depolarization-- Increased ECF
potassium
5)
Adenosine : a potent cerebral vasodilator
저산소증 (Hypoxia)
저산소증은 뇌혈관 확장을
초래한다
1) chemoreceptor in the aortic
arch & carotid body
2) stimulation of locus
ceruleus
3) chemical regulation through
alteration of ECF
composition
고이산화탄소증
(Hypercarbia)
PaCO2 증가
혈관 확장
저이산화탄소증 후 정상 이산화탄소증
(Normocarbia after hypocarbia)
뇌혈관근 마비 (Cerebral Vasomotor
Paralysis)
When ICP approaches the systemic
pressure, cerebral vessels no
longer respond to changes in
carbon dioxide tension.
luxury perfusion:
The amount of blood flowing
through the tissue is in exess of
metabolic needs and does not
imply a particular state of
responsiveness of the vessels.
CPP, ICP, BP and CBF
Cerebral perfusion pressure (CPP)
= arterial inflow pressure - venous
outflow pressure
= mean arterial pressure ( MAP ) - ICP
CBF = CPP / CVR = ( MAP- ICP ) / CVR
ICP = Volume, Brain, Elastance(inverse of
compliance) : Brain, Blood, CSF, Mass
Cerebral perfusion pressure
• 100mmHg in normal
• 40 mmHg (Critical level) > --> cerebral
hypoxia in animal
• 60 mmHg < tolerable in normal condition
• 80-90 mmHg < ideal in ischemic condition
Normal ICP
•
100 - 180 mmH2O (1015mmHg) : measured from
lumbar puncture in lateral
decubitus position
•
Posture dependent, pulsatile
•
Newborn 0.7 - 1.5mm Hg
•
Infant 1.5 - 6.0 mm Hg
•
Children 3.0 - 7.5 mmHg.
Indications for ICP monitoring
Injury
Risk of raised ICP
Severe Head Injury (GCS 3-8)
Abnormal CT scan
50-60%
Normal CT Scan with Age > 40 or BP < 50-60%
90mmHg or abnormal motor posturing
Normal CT scan with No risk factors
13%
Moderate Head Injury (GCS 9-12)
•If anaesthetised/sedated
•Abnormal CT scan
approx. 10-20% will
deteriorate to severe head
injury
Mild Head Injury (GCS 13-15)
•few indications for ICP measurement
Only 3% will deteriorate
Methods of measurement 1
- Spinal tap
Spinal tapping in Brain Herniation
contraindicated in IICP due to space occupying
lesion
can be performed by experienced hands in IICP
without brain shift
ex) Encephalitis, Meningitis, Pseudotumor cerebri,
Hydrocephalus, etc.
Methods of measurement 2
-
Ventricular
puncture
-
Transducer :
1) epidural
2) subdural
3) subarachnoid
4) intraparenchymal
Intracranial Pressure Monitoring Devices I
Intracranial Pressure Monitoring Devices II
Epidural
catheter
Lower risk of infection
No transducer adjustment
with head movement
Unable to recalibrate or zero after
placement. Decreased accuracy sensing
through dura. Unable to drain CSF
Subarach
noid bolt
/screw
No penetration of brain
Decreased risk of
infection. Able to sample
CSF. Direct pressure
measurement
Unable to drain CSF Requires intact skull
Transducer repositioning with head
movement
High pressure may cause herniation of brain
tissue into bolt
Ventriculo
stomy
catheter
CSF drainage and
sampling Direct
measurement of pressure
Risk of intracerebral bleeding or edema
along cannula track. High risk for infection.
Transducer repositioning with head
movement
Fiberoptic
catheter
Versatile, placed in
ventricle or subarachnoid
space No adjustment of
transducer with head
movement
Separate monitoring system required
Catheter relatively fragile
Unable to recalibrate or rezero after
placement
Ultrasonic pulsed-phase locked
loop (PPLL) device
Normal Pressure Waves
•P1 (percussion wave)
represents arterial pulsations
•P2 (rebound wave) reflects
intracranial compliance
•P3 (dichrotic wave) represents
venous pulsations
Abnormal Pressure Waves
Pathologic Pressure
Waves(I)
A wave
type 1 : rhythmic fluctuations in 15 to 30 minutes intervals
type 2 : plateau wave
– pressure up to 60 to 100 mm Hg
– duration from 5 to 20 minutes
– regular or irregular frequency
– frequently with pressure Sx and worsening of neurologic deficit
Pathologic Pressure
Waves(II)
mmHg
B wave
minutes
• one per minute waves
• found in association with Cheyne-Stokes respiration
• postulated to be result of common brain stem
rhythm altering both respiratory and vasomotor tone
Pathologic Pressure
Waves(III)
C wave
mmHg
minutes
• six per minute waves
• associated with Traube-Hering-Mayer blood pressure
waves
• postulated to be result of common brain stem rhythm
altering both blood pressure and cerebral vasomotor
tone
Maintenance of ICP monitoring
•
All monitors have a risk of infection.
1) Infectious risk increases with duration of
monitoring, particularly after the 5
th
day.
2) The site of monitoring is typically changed
every 5-7 days.
3) Prophylactic antibiotics (Ancef) are indicated
for the duration of ICP monitoring.
•
An arterial line is indicated in all patients with an
ICP monitor
Complications of Ventriculostomy
• Ventriculostomy associated haematomas:
About 1.1%
• Bacterial infection/colonisation: About 5%
• Malfunction/obstruction: About 6%
• Malposition: About 3%
Clinical Aspect of IICP
1) Focal CNS signs
2) IICPsigns
3) Brain shift and herniation
signs
Symptoms
Infants:
• bulging fontanelle
• separated sutures
Older children and adults:
• vomiting
• headache
• change in behavior
• progressivedecreased consciousness, may become
coma
• seizures
Cushing’s Reflex
Said to be the the last compensatory
mechanism before herniation
Signs:
1) Increased ICP
2) Widened Pulse Pressure (increased SBP
& decreased DBP)
3) Bradycardia
IICP Sx & Signs 1
Headache ( V, IX, X, C2, 3 )
Non-specific in character, intensity, and
distribution
from 1) venous dilataton
2) traction on bridging cerebral vein
3) stretching of arteries at the base
Morning headache
• With brain swelling from vascular dilatation
and edema secondary to CO2 retension
during sleep.
• Aggrevated by coughing, stooping down.
• Terminated by vomiting accompanied with
hyperventilation
IICP Sx & Signs 2
Vomiting
- Due to IICP
- Due to local lesion in the fourth
ventricle
IICP Sx & Signs 3
Papilledema
• Optic nerve : An extension of brain, complete with
meningeal coverings and subarachnoid space.
• Edema of nerve head and engorged retinal veins.
• Some days need to develop.
• Seldom in infants
• Less of ten in the elderly.
Optic atrophy
papilledema
Normal
IICP Sx & Signs 4
Mental Changes
• from 1) direct compression to mid brain
2) caudal displacement and distortion of
brain stem
• - Alert(Clear), Drowsy, Stuporous, Semicoma, Coma
• Glasgow coma scale
• Sixth nerve palsies can occur due to stretching of
nerve by caudal displacement of the brain stem, but
not common.
Vasodilatation cascade model
Vasoconstriction cascade model
Brain herniations
•
IICP in only one compartment squeeze brain toward
lower pressure area.
• Transfalxial/subfalxial herniation
• Transtentorial herniation (tentorial, temporal, or uncal
cone/herniation)
• Transforaminal herniation (tonsilar or cerebellar
cone/herniation)
• Upward (transtentorial) herniation
1. Transtentorial herniation(I)
: Herniation of uncus and hippocampus via
tentorial incisure
- Ipsilateral 3rd nerve palsy :
1) direct compression
2) mid brain ischemia
3) compressed by petroclival ligament
4) compression or distortion on
entering
cavernous sinus
5) kinked across displaced PCA
or trapped between PCA & SCA
- Hemianopic defect or intermittent total
blindness
by 1) obstruction of PCA
2) compression of optic tract
1. Transtentorial herniation(II)
- Pressure on midbrain --- intermittent
decerebration
- Mental change : due to reticular formation
dysfunction
- Contralateral hemiparesis : due to
compression of cerebral peduncle
- Ipsilateral hemiparesis Kernohan notch pressure of the free edge of the
tentorium against the opposite cerebral
peduncle
- Bradycardia
- High blood pressure
- Decorticate rigidity
- Decerebrate rigidity : Transection of
midbrain
2. Foraminal herniation
Herniation of cerebellar tonsil via foramen
magnum
• Abnormal neck posture
• Stiff neck
• Abnormalities of respiratory rate and
rhythm : - Cheyne-Stokes breathing - a
crescendo of breathings of increasing
depth and frequency followed by a
period of total apnea of up to a minute
or so.
- Apnea is frequently sudden without
impaired consciousness or any other
warning signs
Tentorial Herniation
Site
Structure
Signs
Lateral(Uncal)
Oculomotor
Cbr. peducle
Post Cbr Art
Ptosis, mydriasis, lat. deviation
Hemiparesis
hemianpsia
Post(Tectal)
Quadrigeminal plate Bilat. Ptosis
Upward gaze paralysis
Central(Axial)
Reticular formation
Cortospinal tr.
Midbrain and pons
Depression of consciousness
Decerebrate rigidity
Impairment of eye reflex
Irregular respiration
Arterial hypertension
Bradycardia
Irregular respiration
Subfalcine and tonsilar Herniation
Site
Subfalcine
(Cingulate)
Structure
Signs
Singulate gyrus Leg weakness
Ant. Cbr. Art
Tonsilar(Foramial) Medulla
Sudden apnes
IICP Management (1)
1. Removal of causes
• Mass : Removal of Hematoma, Tumor, Abscess, etc.
• Hydrocephalus : Removal of CSF - Permanent shunt,
Intermittent drainaged by lumbar puncture
• Edema : Steroid
• Cerebrovascular dilatation : Hyperventilation
2. Reduction of brain bulk
• Dehydrating agents : Hyperosmotic agents
- Mannitol, Urea, Glycerol
• Diuretics - Lasix
IICP Management (2)
3. Reduction of CBV
• PCO2 (25-35mmHg) : Hyperventilation
•
Sedation : muscle relaxant, Barbiturate coma, Isoflurane
• Hypothermia with antipyretics, or with active cooler down to
33-35C
4. Surgical Decompression
• Ventriculostomy (EVD)
• Craniectomy
• Extension duroplasty
• Lobectomy: fronatal, temporal
• Cbll lobectomy for cbll infarction
Sedation for ICP
•
Sedation using Versed or Ativan 0.1 mg/kg IV or 0.1
mg/kg/hour continuous infusion.
•
Additional sedation and/or analgesia should be
considered before suctioning, patient transfer,
procedures, etc.
•
In addition Lidocaine 1 mg/kg iv before suctioning may
blunt the increased ICP associated with this
intervention.
•
Neuromuscular blockade can be considered to
decrease any muscle movement (coughing, shivering,
etc.) that might contribute to increased ICP.
Head position
•
Elevation of the
head of the bed
15-30 degrees or
no elevation
•
Keeping the head
midline
Mannitol
•
Decreases blood viscosity resulting in lower
cerebrovascular resistance, reflex cerebral
vasoconstriction and reduction in cerebral blood
volume.
•
May act as an osmotic agent to decrease brain water
with subsequent osmotic diuresis.
•
Dose is 0.25-0.5 gm/kg rapid IVP over ~ 5 min.
•
Goal: reduction in ICP, improvement in CPP or
maximum osmolality of 310-320. If multiple doses are
administered, the patient can be placed on scheduled
mannitol Q4-6 hours. Serum osm and Na are followed
at a similar interval and mannitol is withheld if the osm
are >310. Na typically are in the 150s.
Hyperventilation
•
Hyperventilation causes cerebral arterial constriction
with subsequent decreased cerebral blood flow and
decreased ICP.
•
It is a potentially harmful method of decreasing ICP as
CPP may concomitantly be compromised.
•
Moderate HV to a PCO2 of 30-35 is typically well
tolerated. More extreme hyperventilation is no longer
practiced at most trauma centers.
•
The beneficial effects of HV diminish after 24-48 hours,
due to buffering, however rapid reversal of HV results in
rebound increased ICP. Thus it is important that HV is
weaned slowly (ie. over hours to days).
Barbiturate coma
•
Employed for increased ICP unresponsive to less invasive
therapies.
•
Dose is 5 mg/kg bolus every hour X 3 and an infusion of 1-5
mg/kg/hour titrated up or down to achieve control of
intracranial hypertension or to achieve burst suppression (2-9
bursts/minute on EEG), whichever comes first. Continuous
EEG monitoring is necessary until burst suppression is
achieved, intermittant monitoring may be appropriate once the
patient has stabilized.
•
Hypotension due to cardiac depression is common and
patients frequently require vasopressor support with
epinephrine or norepinephrine. It is prudent to have
vasopressor medications at the bedside before loading with
pentobarb. A pulmonary artery catheter should be considered
to guide management.
Hypothermia
• Mild vs moderate
• Short vs long term
• Early vs late
• With or without barbiturate
• Morbidity and mortality
External Ventricular Drain
• Br J Neurosurg 2001 Aug
• Department of Neurosurgery, University of Illinois at
Chicago
• 103 consecutive cases
• The average duration of EVD was 10.7 days (range
1-28 days).
• Complications
• one case of positive cerebrospinal fluid (CSF)
culture
• one small intraparenchymal hematoma
• two cases of EVD disconnection
Decompressive craniectomy
• High IICP: 30 vs 40 vs 50
• Craniectomy only vs CR + duroplasty vs
CR+ duroplasty + lobectomy
• Frontal lobectomy vs temporal lobectomy
• Morbidity: functional grade (ADL grade)
• Mortality: Survival
Nursing protocol of Victoria
Hospital, London
1)
2)
3)
4)
5)
6)
7)
8)
9)
Nurse:patient ratio of 1:1
Neurological assessment of vital signs a minimum of q.1.h
I.C.P. measurements recorded not less than q1h,
Loss of wave requires notification of the CCTC and
neurosurgery resident, if flushing the transducer and pressure
tubing does not correct the problem.
The flush devise provides extra security against accidental
flushing.
An order MUST BE written to identify at which level the
drainage bag is to be placed
Maintain good neck alignment with head of bed elevated 30.
Maintain as quiet an environment as possible
Temperature will be measured q2h by a core method (ie.,
pulmonary artery.) If a cooling blanket is in use, temperatures
will be measured q1h.
NIH Clinical Center Nursing Department
Care of the Patient with an Intracranial
Pressure (ICP) Monitoring Device
1. Assessment (I)
1.
2.
Neurological Assessment to include Glasgow Coma Scale and:
1)
level of consciousness and mental status
2)
pupil size and shape and light response
3)
extraocular movements and visual acuity
4)
motor movement
5)
extremity strength
6)
headache, nausea, & vomiting
7)
fontanels, cranial sutures, & head circumference for pediatric
patients < 2 years
8)
seizure activity
ICP (normal adults < 10 - 15 mm Hg, pediatric patients: Newborn
0.7 - 1.5mm Hg, Infant 1.5 - 6.0 mm Hg, Children 3.0 - 7.5 mmHg.
NIH Clinical Center Nursing Department
1. Assessment (II)
3.
Cerebral Perfusion Pressure (CPP) (MAP - ICP; normal
70-100 mm. Hg; normal CPP in pediatric patients is
variable and dependent upon the age-related MAP but
should be at least 40-60 mmHg.).
4.
Changes in ICP waveform
5.
Catheter insertion site to include:CSF leakage
6.
1.
Bleeding
2.
Swelling and inflammation
3.
Integrity of dressing
Cerebral Spinal Fluid (CSF) output to include:
1.
Color
2.
Amount
3.
Clarity
NIH Clinical Center Nursing Department
1. Assessment (III)
7.
Patency of system and height of collection chamber or transducer
(if applicable to system)
8.
Changes in ICP related to turning, head position, crying, coughing,
and environmental stimuli.
9.
Vital signs including any widening of pulse pressure.
10. Ventilatory status to include: a. Oxygen saturation
b. Rate, depth, & changing pattern of respirations
c. pH and pCO2 (when ordered)
11. Hydration status to include:
1)
Urine & output, urine specific gravity
2)
skin turgor
3)
serum osmolality
4)
Pulmonary Capillary Wedge Pressure (PCWP) (when ordered)
5)
Central Venous Pressure (CVP) (when ordered)
NIH Clinical Center Nursing Department
Interventions (I)
1.
Verify physician’s orders for hourly ventricular drainage
parameters.
2.
Maintain head of bed flat or raised to a prescribed height as
ordered or depending on ICP and CPP measurements. Clarify head
position with physician.
3.
Maintain head and neck in neutral position. Avoid hyperflexion,
hyperextension, or severe rotation.
4.
Verify the physician’s order for insertion site dressing changes.
5.
Maintain integrity as a closed system.
6.
Inspect the system for kinks and leaks in the circuit.
7.
Change drainage bag when the drainage bag is 3/4 full or in place
for 72 hours (verify with neurosurgeon). Mark drainage bag with
time and date. Maintain aseptic technique. For breaks in the sterile
system, notify MD.
NIH Clinical Center Nursing Department
Interventions (II)
8.
Zero balance and calibrate the system at least q 8 hr. and prn.
9.
Set ICP alarms 10 mm Hg lower and higher than the patient’s
usual range.
10. Secure endotracheal tubes in ways that do not occlude venous
return to the head.
11. Suction patients for less than 10 seconds. If coughing occurs,
consider administering lidocaine via the endotracheal tube per
MD order.
12. Space activities of daily living.
13. Decrease environmental stimuli.
14. Provide cooling measures to maintain normal body temperature.
15. Administer stool softener as per physician order to prevent
constipation and straining.
NIH Clinical Center Nursing Department
Interventions (III)
16. Notify physician for:
1)
Any changes in neurological signs
2)
Elevated ICP and/or values greater than 15 mm Hg.
for 5 minutes or more
3)
CPP greater than 100 mm Hg. or less than 70 mm
Hg.
4)
Temperature or WBC elevation
5)
CSF leakage
6)
Change in CSF drainage amount, color and clarity
7)
Malfunction of the monitoring system.
NIH Clinical Center Nursing Department
Interventions (IV)
17. Troubleshoot the ICP fluid filled system for problems
such as:
1.
Breaks in the system
2.
Dampened waveform
3.
Loss of wave form
4.
Occlusion of tubing
5.
Change in CSF drainage amount
18. Administer sedation per MD order
19. Minimize any increases in intra-abdominal/intrathoracic
pressure (an increase in intra-abdominal pressure may
require gastric decompression)
NIH Clinical Center Nursing Department
Patient and Family Education
1.
Teach regarding the need and rationale to
maintain specific head position.
2.
Teach regarding the effects of
environmental stimuli on ICP.
3.
Discuss family’s role in controlling
environmental stimuli.
NIH Clinical Center Nursing Department
Documentation
1.
Document hourly on the approved Critical
Care Flow Sheet.
2.
Document all nursing assessments and
interventions.
JASTREMSKI CA, College of Nursing, State University of New York Health Science Center
Controlling ICP: The nurse’s role
•
Respiratory support
– When suctioning is warranted, do so for no more than 10 seconds at a time,
providing several breaths of 100% O2 between passes.
– Hyperventilating the patient for about a minute before and after the procedure will
also help reduce the rise in ICP.
– As soon as you remove the suction catheter, hyperinflate the lungs with 100% O 2.
•
Patient positioning
– To avoid neck flexion, make sure the patient’s head and neck are aligned with the
rest of his body.
– When repositioning the patient, use the log roll technique to help avert neck flexion.
– Position the head of the bed at 30 degrees or in the flat position
•
Environmental support
– Keep loud noises, painful procedures, bright lights, and other noxious stimuli to a
minimum; they, too, increase ICP.
– To create a comfortable, familiar environment
– Offer soothing, caring touch. It can help decrease ICP.
Perdue Law Firm Houston, TX
Nursing negligence
• A girl born with hydrocephalus (water on the brain) is
treated successfully with a shunt.
• Twelve years later it becomes necessary to lengthen
the shunt. Following the operative procedure the
shunt becomes kinked.
• This causes the cerebral spinal fluid to press on the
brain. Despite signs of intracranial pressure, the
nurse caring for the girl in the post-surgical unit fails
to alert the surgeon.
• The child experiences brain damage.
Summary
• Intracranial volume and pressure
• ICP vs CBF
• ICP : normal range
• ICP difference on position change
• IICP and Symptoms
• Treatment of IICP
NIH Clinical Center Nursing Department
Care of the Patient Receiving a Continuous
Intracranial Infusion: I. Assessment
1)
The patient's neurological status and vital signs will be
assessed every hour. The minimal neurological
assessment will include:
①
②
③
2)
3)
Level of consciousness and mental status
Cranial nerves 2, 3, 4, 5, 6, 7
Motor power
The patient's head dressing will be assessed every hour.
The nurse will inspect the pump and infusion system every
1 hour for:
①
②
③
④
ntegrity of the catheter and infusion tubing.
Bleeding or drainage at the catheter site.
Infusion rate and volume infused as per physician order
Absence of tension on catheter and tubing.
NIH Clinical Center Nursing Department
II. Interventions
1)
The nurse may reinforce a loose dressing. Complete
dressing change will be performed by the physician.
2) Instruct the patient regarding the symptoms of increased
intracranial pressure.
3) The nurse will instruct the patient to :
① Avoid touching the dressing, infusion tubing, and
pump.
② Call the nurse if the alarm sounds.
③ Call the nurse if any leakage, bleeding or drainage is
noted.
④ Call the nurse for symptoms of increased intracranial
pressure.
4) Monitor Intake and Output throughout the infusion. Record
hourly and cumulative infusion volumes.
NIH Clinical Center Nursing Department
III. Documentation
1)
The patient's neurological status will be
documented in the MIS every 4 hours.
2)
The condition of the infusion site and system
will be documented every 4 hours.
3)
Document intake and output including hourly
infusion amounts in the MIS.
4)
All dressing changes will be documented.
5)
Document the start and end of each infusion
under "Scheduled/Miscellaneous
Medications" in the MIS.
AANN Clinical Guideline
Policies and Goals
• ICP Monitor Placement
– Types of Devices
– Patient Preparation
– Monitor Placement
• Post Placement Management of Fluid Filled and
Fiberoptic Systems
– Patient Assessment
– Patient Care
– System Maintenance
• Trouble Shooting for Fluid Filled and Fiberoptic Systems
– Patient/Family Education
– Documentation
– Removal of the Monitor