Medical Surgical Nursing

Aseptic technique must be used when managing the system and changing the
ventricular drainage bag. The drainage system is also checked for loose connections,
because they can cause leakage and contamination of the CSF as well as inaccurate
readings of ICP. The nurse observes the character of the CSF drainage and reports
observations of increasing cloudiness or blood. The patient is monitored for signs and
symptoms of meningitis: fever, chills, nuchal (neck) rigidity, and increasing or
persistent headache. (See Chapter 64 for a discussion of meningitis.)

Monitoring and Managing Potential Complications
The primary complication of increased ICP is brain herniation resulting in death (see
Fig. 61-2). Nursing management focuses on detecting early signs of increasing ICP,
because medical interventions are usually ineffective once later signs develop. Frequent
neurologic assessments and documentation and analysis of trends will reveal the subtle
changes that may indicate increasing ICP.

Detecting Early Indications of Increasing Intracranial Pressure
The nurse assesses for and immediately reports any of the following early signs or
symptoms of increasing ICP:

 Disorientation, restlessness, increased respiratory effort, purposeless

movements, and mental confusion; these are early clinical indications of

increasing ICP because the brain cells responsible for cognition are extremely

sensitive to decreased oxygenation

 Pupillary changes and impaired extraocular movements; these occur as the

increasing pressure displaces the brain against the oculomotor and optic nerves

(cranial nerves II, III, IV, and VI), which arise from the midbrain and brain

stem (see Chapter 60)

 Weakness in one extremity or on one side of the body; this occurs as increasing

ICP compresses the pyramidal tracts

 Headache that is constant, increasing in intensity, and aggravated by movement

or straining; this occurs as increasing ICP causes pressure and stretching of

venous and arterial vessels in the base of the brain

Detecting Later Indications of Increasing ICP
As ICP increases, the patient's condition worsens, as manifested by the following signs
and symptoms:

 The LOC continues to deteriorate until the patient is comatose.

 The pulse rate and respiratory rate decrease or become erratic, and the blood

pressure and temperature increase. The pulse pressure (the difference between

the systolic and the diastolic pressures) widens. The pulse fluctuates rapidly,

varying from bradycardia to tachycardia.

 Altered respiratory patterns develop, including Cheyne-Stokes breathing

(rhythmic waxing and waning of rate and depth of respirations alternating with

brief periods of apnea) and ataxic breathing (irregular breathing with a random

sequence of deep and shallow breaths).

 Projectile vomiting may occur with increased pressure on the reflex center in

the medulla.

 Hemiplegia or decorticate or decerebrate posturing may develop as pressure on

the brain stem increases; bilateral flaccidity occurs before death.