Master Increased Intracranial Pressure (ICP) Nursing Assessment

Increased pressure in the brain may cause compression of structures such as cranial nerves and arteries. Pressure on these structures can cause a headache. Patients may report a continuous headache that is more severe in the morning.

Changes in vital signs that indicate brainstem compression in patients with increased ICP are irregular respirations, widening pulse pressure, and bradycardia. These three changes are known as Cushing’s Triad and should be treated as a medical emergency.

When the brainstem is compressed due to increased ICP, regulation of breathing is disrupted. This causes irregular, and often slowed, breathing.

Pulse pressure is a measure of the difference between the systolic and diastolic blood pressures. In patients with increased ICP, systolic hypertension occurs, causing a greater, or widening pulse pressure.

Brainstem dysfunction related to increased pressure in the brain will cause a slowing of the heart rate with a full and bounding pulse.

Vomiting that occurs without the forewarning of nausea can be a sign of increased intracranial pressure. Because vomiting can also be seen with gastrointestinal disturbances, further assessment should be conducted before determining the patient has an increased ICP.

Increased pressure on the oculomotor nerve can cause dilation of the pupil(s). Remember, dilation of the pupil occurs ipsilateral, or on the same side, as the compression of the nerve.

Swelling of the optic disc in the eye can occur bilaterally in patients with persistent, increased ICP.

Changes in motor function can occur with increasing pressure in the brain. Decerebrate posture is indicative of midbrain and brainstem dysfunction and is characterized by extension and adduction of the arms, and hyperextension of the legs. Patients will also demonstrate hyperpronation of the arms, and plantar flexion of the feet in this posture. When increased intracranial pressure affects the cerebral cortex, patients will internally rotate and adduct the arms, with flexion of the elbows and wrists. This is called decorticate posturing.