Why pressure rises

The skull is a fixed box containing brain, blood, and cerebrospinal fluid. When one increases, the others must decrease, or pressure rises.

AddedvolumeEdema, bleed,tumorCompensationCSF and bloodshiftICP risesCompensationexhaustedCPP fallsBrainischemiaHerniationBrainstemcompression
ICP progression. Causes include head injury, stroke, tumors, meningitis, and hydrocephalus.

Early vs late signs

Detect the early signs; the late signs mean herniation may be imminent.

EarlyChange in level of consciousnessRestlessness, irritability, confusionHeadache, vomitingSubtle pupil changesWeakness on one sideLateCushing triad: ↑ systolic BP, wide pulsepressureBradycardiaIrregular respirationsFixed, dilated pupil(s)Decorticate or decerebrate posturingvs
Early vs late. Infants may show a bulging fontanel, high-pitched cry, and increasing head circumference.
Glasgow Coma Scale componentScore rangeBest response example
Eye opening1–4Opens eyes spontaneously = 4
Verbal response1–5Oriented conversation = 5
Motor response1–6Obeys commands = 6

Total 3–15. A drop of 2 or more points is significant; a score of 8 or less usually requires airway protection.

Nursing measures to lower ICP

Most nursing actions either improve venous drainage or avoid spikes in pressure.

PositionHead of bed about 30°, head midline, no neck flexionAvoid spikesStraining, coughing, prolonged suction, hip flexionOxygen and CO₂Keep oxygenation and CO₂ in the normal rangeEnvironmentQuiet, dim, clustered care with rest betweenDrugs as orderedMannitol or hypertonic saline; seizure prevention;fever control
Lowering ICP. Stool softeners prevent straining; suction only when needed and briefly.
  • Hypotonic IV fluids (such as 0.45% NaCl) are avoided because they can worsen cerebral edema.
  • Hyperventilation is not routine; brief hyperventilation may be ordered only for signs of herniation.
  • Monitor sodium and serum osmolality with osmotic therapy; monitor urine output with mannitol.

Head injury specifics

Head injury items test hidden bleeding, CSF leaks, and discharge teaching.

ProblemClueNursing action
Epidural hematoma (arterial)Brief loss of consciousness, a lucid interval, then rapid declineEmergency; prepare for surgery
Subdural hematoma (venous)Slower decline; older adults and clients on anticoagulantsMonitor neuro status; report changes
Basilar skull fractureRaccoon eyes, Battle sign (bruising behind ear), CSF from nose or earNo nasal packing, nasal suction, or nasogastric tubes
CSF leakClear drainage; "halo" on gauzeLet it drain onto sterile gauze; report; watch for meningitis

Teach clients discharged after mild head injury to return for worsening headache, vomiting, confusion, unequal pupils, or seizures, and to have someone stay with them.

NGN-style case

Spotting the earliest change.

functions Clinical judgment case — a quieter client

A client admitted after a fall with a small subdural hematoma was alert at 0800. At 1000 the client is drowsy, answers slowly, and the GCS has fallen from 15 to 12. BP 148/82, HR 76. What should the nurse do?

  1. Recognize cues: decreasing level of consciousness and a 3-point GCS drop.
  2. Analyze: early sign of rising ICP from an expanding hematoma.
  3. Notify the provider immediately and anticipate urgent imaging.
  4. Keep the head of bed at about 30°, head midline; check pupils and vital signs frequently.

Answer. Report immediately: a falling GCS is the earliest sign of rising ICP. Anticipate repeat imaging.