LESSON PLAN
ON
INTRA CRANIAL PRESSURE
OBJECTIVES
General objective: At the end of the class, students will be able to gain overview knowledge regarding Intra
cranial pressure.
Specific objectives: At the end of the class, students will be able to:
Define ICP
Explain the objectives of ICP
Know regarding CSF circulation in brain
Explain about ICP monitoring
Discuss about the procedure of Lumbar puncture
Explain about the causes of increased ICP
List out the signs & symptoms of increased ICP
Discuss about the diagnosis of increased ICP
Explain about treatment of increased ICP
List out the complications of increased ICP
Enumerate about decreased ICP
Explain recent research articles.
METHOD
OBJECTIVES TIME CONTENT OF A.V EVALUATI
TEACHING AIDS ON
INTRODUCTION:
Cerebrospinal fluid (CSF) is a clear, colorless, watery fluid that
flows in and around the brain and spinal cord. The brain and
spinal cord make up the central nervous system. It controls
and coordinates everything a person does, including the ability
to move, breathe, see, think, and more.
Cerebrospinal fluid acts like a cushion that helps protect the
brain and spinal cord from sudden impact or injury. The fluid
also removes waste products from the brain and helps the
central nervous system work properly.
Lecture ppt Defined ICP
DEFINITION OF INTRACRANIAL PRESSURE (ICP)
1 min method
It is the pressure exerted by fluids such as cerebrospinal fluid
To define ICP
(CSF) inside the skull and on the brain tissue.
ICP is measured in millimeters of mercury (mmHg) And at
rest, is normally
7–15 mmHg for a supine adult,
3-7mmHg in children, and
1.4-6mmHg in infants.
CSF circulation in brain:
To explain 1 min Lecture Chart Explained
about CSF method about CSF
circulation in circulation in
brain brain
To explain Explained
about ICP 2 min THE MONRO-KELLIE HYPOTHESIS Lecture cum Ppt about ICP
monitoring The Monro-Kellie hypothesis states that because of the limited discussion monitoring
space for expansion within the skull, an increase in any one of
the components causes a change in the volume of the others.
ICP MONITORING:
The monitoring of intracranial pressure (ICP) is used in the
treatment of a number of neurological conditions ranging from
severe traumatic brain injury to stroke and brain bleeds. This
process is called intracranial pressure monitoring.
ICP monitoring is usually used on patients who have
decreased score on the Glasgow Coma Scale, indicating poor
neurologic function. It is also used in patients who have non-
reassuring imaging on CT, indicating compression of normal
structures from swelling.
Invasive
External ventricular drainage
The external ventricular drainage (EVD) method of intracranial
pressure monitoring is the current gold standard. The
placement of an EVD requires a catheter placed into one of
the lateral ventricles from a burr hole made into the skull.
Benefits of an EVD include its ability to not only measure
changes in pressure but also drain CSF as needed, thus
making it both diagnostic and therapeutic. Significantly, an
EVD can also be re-calibrated after placement which is
particularly useful clinically to manage measurement drift.
Risks in the operation to place the EVD are minimal but
include infection and brain bleeds. Drawbacks to EVDs are the
difficulty to place in comparison to other methods -- especially
in the setting of brain swelling or anatomical variation in
ventricle size – and once placed, are at increased risk of
blockage from blood, air bubbles, or other debris.
Intraparenchymal pressure monitor
There are three types of intraparenchymal pressure monitors
(IPM), also called bolts: fiber optic, strain gauge, and
pneumatic sensors.
Fiber optic monitors use changes in light reflected back
from a mirror at the end of the cable to reflect changes
in the ICP.
Strain gauge monitors use a diaphragm that is bent by
surrounding pressure, which is then converted into
electrical signals used to calculate changes in ICP.
Pneumatic sensors are fitted with a balloon which
measures the surrounding pressure, thereby measuring
the ICP.
IPMs are as equally accurate as EVDs, but cannot be
recalibrated after placement, which is a major clinical limitation
of this method of intracranial pressure monitoring. Risks of
IPMs are similar to risks of EVDs as both require a surgical
procedure. However, placement of IPMs is still considered
less invasive than placement of EVDs. Additionally, placement
of IPMs do not require the precision needed for EVD
placement, and they are less affected by structural changes to
the brain such as brain swelling or midline shift. IPMs can be
placed not only in the parenchyma but also in the ventricular,
subarachnoid, subdural, or epidural spaces. Generally, IPMs
are chosen when EVD placement is unsuccessful or if CSF
drainage is determined too likely not be necessary
Continuous brain tissue oxygen tension (PbO2)
This method of intracranial pressure monitoring requires
placement of an oxygen probe into the penumbra, the area
surrounding the injury that is most at risk of secondary injury
from hypoxia. The probe measures levels of oxygen in the
area, with levels under 15mmHg treated with increasing
oxygen levels in the body.
Non-invasive
There are many noninvasive methods for intracranial pressure
monitoring such as transcranial doppler (TCD), and optic
nerve sheath diameter (ONSD). While none of these methods
have been able to have the accuracy, reliability, and
independent validation of invasive methods, they may
eventually be used in determining the severity of injury and if
1 min there is a need for more invasive measures. Discussion
CAUSES OF INCREASED ICP: method Handout Explained
Causes of increased intracranial pressure can be classified by about the
To explain
the mechanism in which ICP is increased: causes of
about the
Mass effect such as brain tumor, infarction with edema, increased
causes of
contusions, subdural or epidural hematoma, or ICP
increased ICP
abscesses all tend to deform the adjacent brain
Generalized brain swelling can occur in ischemic-
anoxia states, acute liver failure, hypertensive
encephalopathy, hypercarbia (hypercapnia), and Reye
hepatocerebral syndrome. These conditions tend to
decrease the cerebral perfusion pressure but with
minimal tissue shifts.
Increase in venous pressure can be due to venous
sinus thrombosis, heart failure, or obstruction of
superior mediastinal or jugular vein.
Obstruction to CSF flow and/or absorption can occur in
hydrocephalus (Blockage in ventricles or subarachnoid
space at base of brain, e.g., by Arnold–Chiari
malformation), extensive meningeal disease (e.g.,
infection, carcinoma, granuloma, or hemorrhage), or
obstruction in cerebral convexities and superior sagittal
sinus (decreased absorption).
Increased CSF production can occur in meningitis,
subarachnoid hemorrhage, or choroid plexus tumor.
Idiopathic or unknown cause
Too much cerebrospinal fluid (the fluid around your
brain and spinal cord)
Brain hemorrhages
Cerebral edema
Aneurysm
Blood pooling in some part of the brain
Brain or head injury
Brain tumor
Infections such as encephalitis or meningitis
Hydrocephalus
High blood pressure
Stroke
To list out the 2 min SIGNS OF INCREASED ICP: Listed out
signs & Lecture cum Flash the signs &
In general, symptoms and signs that suggest a rise in ICP
Discussion cards
symptoms of include headache, vomiting without nausea, ocular palsies, symptoms
increased ICP altered level of consciousness, back pain, and papilledema. If of increased
papilledema is protracted, it may lead to visual disturbances, ICP
optic atrophy, and eventually blindness. A headache is
classically a morning headache that may wake a person up.
The brain is relatively poorly supplied by oxygen as a result of
mild hypoventilation during the sleeping hours, and cerebral
edema may worsen during the night due to the lying position.
The headache is worse on coughing, sneezing, or bending
and progressively worsens over time. There may also be
personality or behavioral changes
These are the most common symptoms of an ICP:
Headache
Blurred vision
Feeling less alert than usual
Vomiting
Changes in the behavior
Weakness or problems with moving or talking
Lack of energy or sleepiness
3 min Discussion Ppt
DIAGNOSIS: method Knows
To know about
the diagnosis To diagnose ICP, about the
of increased Medical history and physical exam including a diagnosis of
ICP neurological exam to test senses, balance and mental increased
status ICP
Spinal tap (also called lumbar puncture), which
measures the pressure of cerebrospinal fluid
Computed tomography (CT) scan, the gold standard
imaging test, creates a series of cross-sectional X-ray
images of the head and brain
Magnetic resonance imaging (MRI) (used after the
initial assessment) uses magnetic fields to detect subtle
changes in brain tissue content and can show more
detail than X-rays or CT
Positron Emission Tomography (PET)
Trans cranial doppler studies
GLASGOW COMA SCALE:
To explain
about the Lumbar puncture:
procedure of
Lumbar Explained
puncture about the
procedure
of Lumbar
puncture.
.
An LP can be performed with the patient in the lateral
recumbent or prone positions or sitting upright. The correct
level of entry of the spinal needle is most easily determined
with the patient sitting upright or side-lying. The highest points
of the iliac crests should be identified visually and confirmed
by palpation; a direct line joining these is a guide to the fourth
lumbar vertebral body. However, this line may intersect the
spine at points ranging from L1-L2 to L4-L5 and tends to point
to a higher spinal level in females and in patients with obesity.
The spinal needle can be safely inserted into the subarachnoid
To explain space at the L3-4 or L4-5 interspace, since this is well below
about the termination of the spinal cord in most patients. Lecture cum
treatment of 1 min TREATMENT: Discussion Ppt
increased ICP The treatment for ICP depends on the cause. In addition to Explained
management of the underlying causes, major considerations about
in acute treatment of increased ICP relates to the treatment of
management of stroke and cerebral trauma. increased
Ventilation: ICP
In people who have high ICP due to an acute injury, it is
particularly important to ensure adequate airway, breathing,
and oxygenation. Inadequate blood oxygen levels (hypoxia) or
excessively high carbon dioxide levels (hypercapnia) Causes
cerebral blood vessels to dilate, increasing the flow of blood to
the brain and causing the ICP to rise. Inadequate oxygenation
also forces brain cells to produce energy using anaerobic
metabolism, which produces lactic acid and lowers pH, also
dilating blood vessels and exacerbating the problem.
Conversely, blood vessels constrict when carbon dioxide
levels are below normal, so hyperventilating a person with a
ventilator or bag valve mask can temporarily reduce ICP.
Hyperventilation was formerly a part of the standard treatment
of traumatic brain injuries, but the induced constriction of blood
vessels limits blood flow to the brain at a time when the brain
may already be ischemic—hence it is no longer widely used.
Furthermore, the brain adjusts to the new level of carbon
dioxide after 48 to 72 hours of hyperventilation, which could
cause the vessels to rapidly dilate if carbon-dioxide levels
were returned to normal too quickly. Hyperventilation is still
used if ICP is resistant to other methods of control, or there
are signs of brain herniation, because the damage herniation
can cause is so severe that it may be worthwhile to constrict
blood vessels even if doing so reduces blood flow. ICP can
also be lowered by raising the head of the bed, improving
venous drainage. A side effect of this is that it could lower
pressure of blood to the head, resulting in a reduced and
possibly inadequate blood supply to the brain. Venous
drainage may also be impeded by external factors such as
hard collars to immobilize the neck in trauma patients, and this
may also increase the ICP. Sandbags may be used to further
limit neck movement.
MEDICATIONS:
For long-term or chronic forms of raised ICP, especially
idiopathic intracranial hypertension (IIH), a specific type of
diuretic medication (acetazolamide) Is used.
In cases of confirmed brain neoplasm, dexamethasone is
given to decrease ICP. Although the exact mechanism is
unknown, current research shows that dexamethasone is
capable of decreasing peritumoral water content and local
tissue pressure to decrease ICP.
Mannitol or hypertonic saline may be used to decrease ICP.
Surgery:
♦ Craniotomies are holes drilled in the skull with the help
of cranial drills to remove intracranial hematomas or
relieve pressure from parts of the brain. As raised ICP's
may be caused by the presence of a mass, removal of
this via craniotomy will decrease raised ICP's.
♦ A drastic treatment for increased ICP is decompressive
craniectomy, in which a part of the skull is removed and
the dura mater is expanded to allow the brain to swell
without crushing it or causing herniation. The section of
bone removed, known as a bone flap, can be stored in
the patient's abdomen and resisted back to complete
the skull once the acute cause of raised ICP's has
resolved. Alternatively, a synthetic material may be
To list out the used to replace the removed bone section
complications (cranioplasty) Lecture
of increased 1 min COMPLICATIONS OF INCREASED ICP: method Ppt
ICP ICP has serious complications, such as: Listed out
Seizures the
Stroke complication
Neurological damage s of
Death increased
To explain
ICP
about Low ICP
decreased ICP 1 min Spontaneous intracranial hypotension may occur as a method
Lecture
ppt
result of an occult leak of CSF into another body cavity. More Explained
commonly, decreased ICP is the result of lumbar puncture or about
other medical procedures involving the brain or spinal cord.
decreased
Various medical imaging technologies exist to assist in
ICP
identifying the cause of decreased ICP. Often, the syndrome is
self-limiting, especially if it is the result of a medical procedure.
If persistent intracranial hypotension is the result of a lumbar
puncture, a "blood patch" may be applied to seal the site of
CSF leakage. Various medical treatments have been
proposed; only the intravenous administration of caffeine and
theophylline has shown to be particularly useful.
To discuss 2 min Discussion Chart
about nursing method
management Discussed
NURSING MANAGEMENT: about
NURSING DIAGNOSIS: nursing
Ineffective airway clearance related to diminished managemen
protective reflexes (cough, gag) as evidenced by his / t
her respirations.
Ineffective breathing pattern related to neurologic
dysfunction (brain stem compression, structural
displacement) as evidenced by his / her vital signs.
Ineffective cerebral tissue perfusion related to the
effects of increased ICP as evidenced by restlessness
and slow reflexes.
Deficient fluid volume related to fluid restriction.
Risk for infection related to ICP monitoring system
(fiberoptic or intraventricular catheter)
Risk for injury related to increased ICP.
Disturbed sensory perception related to increased ICP
as evidenced by altered sensorium.
Deficient knowledge related to lack of exposure to
altered ICP as evidenced by his/ her repeated
questioning.
NURSING INTERVENTIONS:
Assessed respiratory and neurological status
Vital Sign’s Monitored and Documented
Checked laboratory Tests like Cerebral perfusion
pressure
Administered oxygen as ordered
Given medication therapy as order
Maintained Nutritional and food status
Maintained diet plan, given soft and healthy meal
according to dietitian’s order
Suctioned as needed
kept the patient in semi-Fowler’s positions
Provided healthy and comfortable environment
educated clients about every kind of procedure
assisted with turning, coughing, and deep breathing
Maintained the position and patency of the NG tube
Enforced bed rest
provided mouth care and skin care
Provided skin care
changed position every hourly to prevent bed sore
Maintained seizure precautions
Provided emotional support to client’s and his family.
EVALUATION:
Maintained normal ICP levels.
Vital signs within normal limits.
Fluid volume maintained within normal limits.
Cerebral tissue perfusion was maintained normally.
RECENT RESEARCH ARTICLES:
Steven William Bothwell et al. conducted a study on ―Cerebrospinal fluid dynamics and intracranial pressure elevation in
neurological diseases” in 2019.
Abstract:
The fine balance between the secretion, composition, volume and turnover of cerebrospinal fluid (CSF) is strictly regulated.
However, during certain neurological diseases, this balance can be disrupted. A significant disruption to the normal CSF circulation
can be life threatening, leading to increased intracranial pressure (ICP), and is implicated in hydrocephalus, idiopathic intracranial
hypertension, brain trauma, brain tumors and stroke. Yet, the exact cellular, molecular and physiological mechanisms that
contribute to altered hydrodynamic pathways in these diseases are poorly defined or hotly debated. The traditional views and
concepts of CSF secretion, flow and drainage have been challenged, also due to recent findings suggesting more complex
mechanisms of brain fluid dynamics than previously proposed. This review evaluates and summarizes current hypotheses of CSF
dynamics and presents evidence for the role of impaired CSF dynamics in elevated ICP, alongside discussion of the proteins that
are potentially involved in altered CSF physiology during neurological disease. Undoubtedly CSF secretion, absorption and
drainage are important aspects of brain fluid homeostasis in maintaining a stable ICP. Traditionally, pharmacological interventions
or CSF drainage have been used to reduce ICP elevation due to over production of CSF. However, these drugs are used only as a
temporary solution due to their undesirable side effects. Emerging evidence suggests that pharmacological targeting of aquaporins,
transient receptor potential vanilloid type 4 (TRPV4), and the Na +–K+–2Cl− cotransporter (NKCC1) merit further investigation as
potential targets in neurological diseases involving impaired brain fluid dynamics and elevated ICP.
SUMMARY:
I summarized my topic Intra cranial pressure, ICP monitoring, increased ICP, definition, causes, signs & symptoms, diagnosis,
treatment, complications and decreased ICP.
CONCLUSION:
I conclude my topic. The group will get an idea about the ICP monitoring, signs & symptoms and treatment of increased ICP.
BIBLIOGRAPHY:
Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition, Lippincott Williams & Wilkins, 2021, P.no: 1850-
1873
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for
interprofessional collaborative care. St. Louis, MO: Elsevier. P.NO: 592- 598.
Feng J, Yang C, Jiang J (July 2021). "Real-world appraisal of intracranial pressure monitoring". The Lancet. Neurology. 20
(7): 502–503.
Graham, D. I.; Gennarelli, T. A. (2000). "Pathology of Brain Damage After Head Injury". In Cooper, Paul Richard; Golfinos,
John. Head Injury (4th ed.). McGraw-Hill. pp. 133–54.
https://en.wikipedia.org
https://www.hopkinsmedicine.org
https://nursestudy.net
