itical Care Evaluation

EFFECTS OF NURSING
INTERVENTIONS ON
INTRACRANIAL PRESSURE
By DaiWai M. Olson, RN, PhD, CCRN, Molly M. McNett, RN, PhD, CNRN, Lisa S.
Lewis, RN, MSN, CNE, Kristina E. Riemen, BA, Cynthia Bautista, RN, PhD, CNRN,
CCNS, ACNS-BC

Background Intracranial pressure is a frequent target for goal-

©2013 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2013751
directed therapy to prevent secondary brain injury. In critical
care settings, nurses deliver nnany interventions to patients
having intracranial pressure nnonitored, yet few data document-
ing the immediate effect of these interventions on ¡ntracranial
pressure are available.
Objective To exannine the relationship between intracranial
pressure and specific nursing interventions observed during
routine care.
Methods Secondary analysis of prospectively collected obser-
vational data.
Results During 3118 minutes of observation, 11 specific nurs-
ing interventions were observed for 28 nurse-patient dyads from
16 hospitals. Family members talking in the room, administer-
ing sedatives, and repositioning the patient were associated
with a significantly lower intracranial pressure. However,
intracranial pressure was sometimes higher, lower, or unchanged
after each intervention observed. '
Conclusion Response of intracranial pressure to nursing inter-
ventions is inconsistent. Most interventions were associated
with inconsistent changes in intracranial pressure at 1 or 5
minutes after the intervention. {American Journal of Critical
Care. 2013;22:431-438)

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 M
onitoring intracranial pressure (ICP) in critically ill patients at risk for sec-
ondary brain injury is a multidisciplinary intervention. Recent research
highlights the wide practice variations associated with monitoring, treating,
and documenting ICP values in the intensive care unit (ICU).' The most
common methods of ICP monitoring are a tunneled ventriculostomy
catheter, a bolt-secured intraventricular catheter, or an intraparenchymal catheter.' Without
regard to a specific system, members of the medical and nursing staff are responsible for col-
laboratively managing ICP and delivering interventions designed to ensure that ICP values
remain within some prescribed range.^

Despite the multidisciplinary nature of ICP
management, it is the nurses who provide direct
care and implement most interventions for patients
who have ICP monitors. Although some interven-
tions are specifically targeted to
reduce ICP, a variety of interven-
Wide practice tions may directly or indirectly
variations exist affea ICP." " The impact of these
interventions has not been well
for monitoring, described. A few select studies''"
treating, and have been done to investigate statis-
tical correlations between a specific
documenting intra- intervention and ICP values. The
purpose of this study is to explore
cranial pressure the association between a wide vari-
in the ICU. ety of nursing interventions and
change in ICP.
Review of Literature
Evidence indicates that roudne nursing inter-
ventions may affect physiological variables, leading
to secondary brain injury. Specifically, endotracheal
suctioning and repositioning of patients are associated
with changes in blood pressure, ICP, cerebral perfu-
sion pressure, and heart rate in critically ill neurologi-
cally impaired padents."" In contrast, administration
About the Authors
DaiWai M. Olson was an assistant professor at Duke
University Medical Center, Durham, North Carolina,
when this article was written. He is now an associate
professor in the Department of Neurology and Thera-
peutics at University of Texas Southwestern Medical
Center in Dallas. Molly M. McNett is director of nursing
research at Metrohealth Medical Center in Cleveland,
Ohio. Lisa S. Lewis is a nursing instructor at Watts
School of Nursing in Durham, North Carolina. Kristina
E. Riemen is a clinical research coordinator at Duke
University Medical Center. Cynthia Bautista is a clinical
nurse specialist at Yale-New Haven Hospital in New
Haven, Connecticut.
Corresponding author: DaiWai M. Olson, RN, PhD, CORN,
5323 Harry Hines Blvd, Dallas, TX 75390-8897 (e-mail:
DaiWai.Olson@UTSouthwestern.edu).
of oral care by using either manual or electric tooth-
brushes among intubated neurologically impaired
patients does not result in significant increases in
ICP."" Similarly, Olson et al, in a series of 3
articles,'™-^' explored the effects of chest percussion
therapy on ICP, finding that such therapy does not
adversely affea ICP and may be associated with lower
ICP for some patients. Although these interventions
are often necessary to provide adequate care for crit-
ically ill patients, as they reduce risk of ventilator-
associated pneumonia and pressure ulcers, other
nursing interventions are performed with the aim of
specifically decreasing ICP values. These include talk-
ing with the patient, repositioning endotracheal tubes
or cervical collars, draining cerebrospinal fluid (CSF),
limiting environmental stimulation, raising the
head of the bed, and administering medications.
Despite research indicating that nurses routinely per-
form these and other psychosocial-related interven-
tions among critically ill neurological patients,"*" no
studies have explored the immediate effects of these
interventions on ICP values. Data are needed to
determine how these interventions affect ICP.
Methods
This study is a secondary analysis of the SIM
City data. The SIM City (Study of ICP Monitoring in
Critically 111) study was a multicenter observational
study; the methods and initial results describing
practice variation associated with ICP monitoring
are reported elsewhere.' The SIM City study was a
prospective observational study approved by an
institutional review board. Patients at participating
hospitals were considered eligible if they were adults
(>18 years old) with ICP monitoring for a neuro-
logical injury and they were admitted to an ICU.
Nurses were eligible if they were assigned as the
primary nurse to care for a patient enrolled in the
study. Eligible patients were identified by the site coor-
dinator, who approached the care nurse for consent
first. Then, if the nurse agreed to participate, the

432 A)CC AMERICAN JOURNAL OF CRITICAL CARE, September 2013, Volume 22, No. 5 www.ajcconline.org
Table 1
Number of observations for each intervention
Intracranial pressure
1 min after the intervention, was 5 min after the intervention, was
Intervention Total Lower Tbe same Higher Lower The same Higher
1
Drain cerebrospinal fluid 1593 257 1079 257 380 823 390
Limit stimulation 1250 187 873 190 328 612 310
Family talking to patient 1082 221 635 226 347 428 307
Raise head of bed 372 64 240 68 99 142 131
Nurse talking to patient 353 65 212 76 104 139 110 Î,!
Repositioning 150 34 76 40 55 43 52
Adjust sedation 140 36 71 33 59 42 39
Test/laboratory/radiography 107 15 75 17 26 56 25
Patient moves self 80 23 38 19 41 18 21 i;
Chest physiotherapy 67 17 35 15 19 25 23
Suction 54 10 32 12 15 25 14
Provide analgesia 29 7 16 6 11 6 12
Reposition endotracheal tube 17 4 11 2 5 9 3
Provide anxiolysis 11 3 5 3 3 2 6
Blood pressure medications 9 1 4 4 1 2 6
Reposition cervical collar 3 2 0 1 2 0 1
Administer mannitol 2 0 2 0 1 0 1

patient or the patient's legally authorized represen- Results

tative provided consent. Once consent had been
given, each site investigator was positioned to be
able to observe all activities inside the patient's room.
At the start of the nearest hour after consent had
been given, each nurse-patient dyad was observed
continuously for 2 hours, with recordings made
once each minute. Observations of nursing inter-
ventions and patients' vital signs were made directly
onto an electronic spreadsheet, or onto a paper
spreadsheet and then transferred to the electronic
spreadsheet, for data aggregation.
For this analysis, the primary outcome variable
of ICP change was derived as the baseline ICP minus
the current ICP. ICP change, explored at 1 minute
and 5 minutes after an intervention, was scored as
"lower" if the value was a negative number, scored
as "same" if the value was equal to zero, or scored
as "higher" if the value was a positive number. A
second derived variable was created to explore sig-
nificant change in ICP, wherein "significant" was
based on input from a clinician (nurse or physician)
and defined as a minimum absolute change in ICP
of 2 mm Hg from baseline.
Data were aggregated in an electronic spread-
sheet and statistical analyses were performed by
using SAS v9.4 for Windows.
The demographics for the 28 nurse-patient
dyads enrolled from 16 US hospitals have been pre-
viously reported in a manuscript discussing practice
variations associated with ICP monitoring.' Briefiy,
patients were a mean of 47 years old, primarily male
(68%), and 75% were white. Admission diagnoses
were primarily subarachnoid hemorrhage (21%),
intracerebral hemorrhage (32%), and traumatic brain
injury (21%). Although age was not recorded for the
nurses, 79% were white, 90% were female, and 83%
had baccalaureate or higher education, but fewer than
half (38%) held specialty nursing certification.
There were 3118 minutes of direct observation.
Table 1 provides frequency counts for ICP change
being scored as "lower," "same," or "higher" at 1 and
5 minutes after each intervention. The 3 most com-
monly observed interventions were (1) draining CSF
(n= 1593), (2) limiting stimulation (n= 1250), and
(3) family talking to the patient (n= 1082). After
CSF drainage, the ICP was lower in 16.1% of obser-
vations at 1 minute and 23.9% of observations at 5
minutes. After CSF drainage, the ICP was the same
in 67.7% of observations at 1 minute and 51.7% of
observations at 5 minutes. After CSF drainage, the
ICP was higher in 16.1% of observations at 1 minute
and 24.5% of observations at 5 minutes. When the

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 Table 2 t
Reporting the number of observations in which the change
in intracranial pressure was >2 mm Hg after an intervention

Intracranial pressure

1 min after the intervention, was 5 min after the intervention, was
The same Higher The same Higher

Drain cerebrospinal fluid 1593 39 1510 44 95 1388 110

Limit stimulation 1250 23 1198 29 73 1105 72
Family talking to patient 1082 41 1004 37 112 884 86
Raise head of bed 372 4 361 7 17 328 27
Nurse talking to patient 353 11 323 19 29 288 36
Repositioning 150 14 122 14 34 99 17
Adjust sedation 140 1 138 1 7 127 6
Test/laboratory/radiography 107 2 105 0 9 93 5
Patient moves self 80 4 69 7 17 55 8
Chest physiotherapy 67 3 60 4 5 52 10
Suction 54 3 49 2 7 40 7
Provide analgesia 29 0 28 1 2 22 5
Reposition endotracheal tube 17 0 17 0 3 14 0
Provide anxiolysis 11 0 11 0 1 7 3
Blood pressure medications 9 0 9 0 0 8 1
Reposition cervical collar 3 0 2 1 0 2 1
Administer mannitol 2 0 2 0 0 2 0

definition of significant change (>2 mm Hg) was
applied, ICP was lower after CSF drainage for 2.4%
of 1-minute observations and 6.0% of 5-minute obser-
vations and was higher for 2.8% of 1-minute observa-
tions and 6.9% of 5-minute observations (Table 2).
Similarly, after stimulation was limited, ICP was
significantly (>2 mm Hg) lower in 1.8% of 1-minute
and 5.8% of 5-minute observations and was signifi-
cantly higher in 2.3% of 1-minute and 5.8% of 5-minute
observations. ICP was unchanged after stimulation
was limited in 95.8% of 1-minute and 88.4% of 5-
minute observations. The most ftequent nursing inter-
ventions for ICP did not result in immediate (ie, within
1 minute) or significant (>2 mm Hg) increases in ICP.
Associations between interventions and change
in ICP were examined ftirther by calculating odds
ratios for the top 11 interventions (Table 3). The
variables of adjusting sedation (giving an additional
dose or altering a continuous inftision), providing
analgesia, and providing anxiolysis were combined
into 1 variable for these analyses and were labeled
"sedative/analgesic." Analyses were first performed
by exploring effects of interventions on 1-minute ICP
values. Findings indicate that the odds of observing a
lower ICP value were significantly higher 1 minute
after administration of a sedative/analgesic medication
(odds ratio, 1.54; 95% CI, 1.05-2.24; P=.O3) and
after family were talking in the room (odds ratio,
1.32; 95% CI, 1.08-1.61; P=.OO7). Conversely, the
odds of observing a lower ICP 1 minute after limit-
ing stimulation were low (odds ratio, 0.80; 95% CI,
0.65-0.98; P= .03), indicating that this intervention
was not likely to decrease ICP values within 1 minute.
The remaining interventions (CSF drainage, head-of-
bed elevation, nurse talking to the patient, reposition-
ing, tests/radiography, patients moving themselves,
chest percussion, and suctioning), were not associ-
ated with a lower ICP 1 minute later.
Analyses were then performed to explore change
in ICP 5 minutes after an intervention. The odds of
observing a lower ICP value was significantly higher
5 minutes after administration of a sedative/analgesic
medication (odds ratio, 1.59; 95% CI, 1.13-2.22;
P= .008), after family were talking in the room (odds
ratio, 1.47; 95% CI, 1.24-1.75; P<.001), and after
repositioning the patient (odds ratio, 1.74; 95%CI,
1.22-2.50; P = .003). Additional interventions (CSF
drainage, limiting stimulation, head-of-bed elevation,
nurse talking to the patient, tests/radiography per-
formed, patient moving self chest percussion, and
suctioning) were not associated with a lower ICP 5
minutes later.

434 A)CC AMERICAN lOURNAL OF CRITICAL CARE, September 2013, Volume 22, No. 5 www.ajcconline.org
 Table 3 ^
Odds of observing a lower intracranial pressure (vs it being
the same or higher) 1 min or 5 min after each intervention

1 min after the intervention, was 5 min after the intervention, was
1 Intervention performed Odds ratio 95% CI lower 95% CI upper P Odds ratio 95% CI lower 95% CI upper P

Cerebrospinal fluid drainage 1.02 0.85 1.24 .81 1.11 0.93 1.31 .26
Limit stimulation 0.80 0.65 0.98 .03 1.03 0.87 1.22 .76
Family talking in room 1.32 1.08 1.61 .007 1.47 1.24 1.75 <.OO1
Head-of-bed elevation 0.85 0.64 1.14 .29 0.82 0.64 1.05 .12
Nurse talking to patient 1.16 0.86 1.55 .35 1.25 0.97 1.62 .09
Repositioning 1.49 1.00 2.24 .05 1.74 1.22 2.50 .003

Sedative/analgesic 1.54 1.05 2.24 .03 1.59 1.13 2.22 .008

Test/radiography 0.98 0.55 1.74 .95 1.14 0.71 1.84 .59

Move self 1.83 1.11 3.01 .02 2.76 1.74 4.36 <.OO1
Chest percussion 1.42 0.81 2.48 .22 0.98 0.57 1.69 .95
Suctioning 1.18 0.58 2.40 .70 1.18 0.63 2.21 .62

Discussion without a reciprocal change in either of the other

Findings from this study indicate that the most
common nursing interventions for ICP management
include draining CSF, limiting stimulation, and
facilitating family members' talking to the patient.
Very few studies have addressed continuous versus
intermittent CSF drainage and neither was man-
dated as this was an observational study of current
practice.^' Interestingly, neither CSF drainage nor
limiting stimulation had a significant effect on ICP
values at 1-minute or 5-minute intervals. However,
our analyses suggest that having family talking in
the room and administration of sedative medica-
tions were effective in decreasing ICP values at both
1 and 5 minutes. Further, repositioning the patient
resulted in lower ICP values at 5 minutes.
It is clear that ICP does not have a consistent
response to any 1 given nursing intervention.
Observational, anecdotal, case study, and expert
opinion argue against the assumption that nursing
interventions never affect ICP. Therefore, the
remainder of this discussion requires the assump-
tion that although nursing interventions can affect
ICP, the magnitude and context of this variability
remains undefined. It seems likely that the effect of
nursing interventions on ICP is dependent upon
the context in which the intervention is delivered.
The most frequently performed intervention
was CSF diversion. The theoretical basis supporting
CSF diversion as a method of reducing ICP is prin-
cipally derived from the Monro-Kellie doctrine.^''
In 1783, Alexander Monro, and then George Kellie
in 1824, posited that the 3 contents within the
skull (blood, brain, and CSF) exist in a dynamic state;
a change in the volume of 1 of these 3 contents
2 will result in a change in pressure." This doctrine,
however, does not account for context of care. For
example: CSF diversion in the context of a heavily
sedated patient with an ICP less than 10 mm Hg
may differentially affect ICP when compared with
CSF diversion for a nonsedated patient with an ICP
greater than 30 mm Hg.
Despite the widespread practice of CSF diver-
sion to reduce ICP, no guidelines that support this
practice in the critical care setting are available.
Our finding that CSF diversion does not predictably
reduce ICP is consistent with published research.
The only study to date finding sup-
port for CSF diversion as an ICP After drainage of
reduction strategy is the study by
Kerr et al." In this study of 58 cerebrospinal
patients, ICP was not reduced by fluid, intracranial
CSF drainage if the baseline ICP
was less than 25 mm Hg, or if the pressure was sig-
nurse was unable to drain at least 3
mL of CSF. A modest benefit of
nificantly lower in
10.1% ICP reduction was noted in 6%, but higher in
patients with a mean baseline ICP
of 26.2 mm Hg and 3 mL of CSF 6.9% of 5-minute
drainage." In a 2011 study^' of con- observations.
tinuous CSF drainage, researchers
found no difference in ICP reduction for patients
with traumatic brain injury. More recently, in a study^'
of CSF drainage in patients with subarachnoid
hemorrhage, researchers reported no difference in
mean ICP values for patients with continuous ver-
sus intermittent CSF drainage.
Two of the more common interventions involved
talking. Observations of the nurse talking to the

www.ajcconline.org A)CC AMERICAN JOURNAL OF CRITICAL CARE, September 2013, Volume 22, No. 5 435
 patient were scored separately from observations
of patients' family members talking to patients.
The nurse talking to the patient is clearly recognized
as a nursing intervention.''"'" In the ICU, the nurse
is often the gatekeeper and therefore, it is reasonable
to assume that the nurse facilitates
Repositioning and encourages patients' family
members to interact with the
the patient was patient."^' Having family members
talk to or around the neurologically
associated with impaired patient in our study was
lower intracra- associated with an increased likeli-
hood of decreasing ICP values at 1-
nial pressure and 5-minute intervals. Previous
5 minutes after research has investigated effects of
different types of sensory stimula-
the intervention. tion, including talking, on mini-
mally conscious patients.
Cumulative findings from these studies indicate
that the evidence is insufficient to firmly conclude
that these interventions improve neurologic out-
come.™ However, 1 study was done specifically to
investigate the effects of familiar voices (ie, family
members) versus unfamiliar voices on ICP values."
That study showed no significant change in ICP asso-
ciated with verbal stimuli and no difference
between the effects of familiar and unfamiliar
voices on patients' ICP values, indicating that this
intervention is safe and can be performed by family
and ICU staff. Our findings support this conclusion
and suggest that talking by family members may
even decrease ICP values.
As an example of an intervention that may
increase ICP, suctioning is considered. In our study,
the patient was suctioned in 54 cases. After suction-
ing, most patients had unchanged ICP measure-
ments: 91% (49/54) at the 1-minute time and 74%
(40/54) at the 5-minute time. ICP measurements
after suctioning were higher in only
4% (2/54) of cases at the 1-minute
Having family time and in 13% (7/54) of cases at
talking in the the 5-minute time. The ICP meas-
urement was actually lower at the
room decreased 1-minute time for 6% (3/54) of
cases and 13% (7/54) at the 5-
intracranial minute time. It is possible that the
pressure. suctioning was prompted by the
patient coughing, thus resulting in
a higher ICP measurement before suctioning than
that measured after the airway was cleared and the
patient was no longer coughing. Other studies"'"'"
have demonstrated adverse effects of endotracheal
suctioning on ICP values, and it often takes up to 2
full minutes before hemodynamic and ICP values
436 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2013, Volume 22, No. 5
return to baseline." It is apparent from our study
and others that there is most likely a multitude of
factors that may infiuence ICP values immediately
before, during, and after suctioning, such as cough-
ing, hypoxia, and even hyperventilation." Future
research incorporating intracranial pressure wave-
form analysis to determine individual effects of
each activity may prove to be a valuable adjunct
for nursing care."
Observations of the use of individual pharma-
cotherapies were minimal. The most probable expla-
nation for this is that patients were observed for
only a single 2-hour period. However, when data
for sedative, analgesic, and anxiolytic medications
were aggregated, findings reveal a decrease in ICP
values at both 1- and 5-minute intervals. In a recent
retrospective study, Pascual et al" report that
administration of sedatives or narcotics is one of
the most common interventions for patients with
ICP monitoring, specifically when treating brain tis-
sue oxygénation, yet such administration does not
consistently yield clinically significant decreases in
ICP values. Kirkness et aF* reported that administra-
tion of analgesics among patients with aneurysmal
subarachnoid hemorrhage is significantly correlated
with ICP variability, yet administration may aaually
increase median ICP values. Despite the different
types of medications used and the various conclu-
sions about the effects of these medications on ICP
values, administration of such medications remains
a cornerstone of neurocritical care.
Last, the intervention of repositioning the patient
resulted in decreased ICP values after 5 minutes. The
act of repositioning itself is likely to increase ICP
initially, so it is not surprising that decreases in ICP
values are not seen until 5 minutes after this inter-
vention. Early research examining the effects of spe-
cific nursing interventions on ICP management
demonstrates that repositioning results in immedi-
ate increases in ICP values.^*" However, no studies
have been done to examine the ICP response in tfie
period after the repositioning has occurred. Our
finding suggests that ICP levels do not merely return
to baseline but are actually lower after the patient
has been repositioned.
Limitations
Several limitations of these data must be rec-
ognized. The observational nature of these data is
both a strength and weakness. Observation allows
the reality of practice to be examined, but does
not allow hard conclusions regarding the efficacy
of any given intervention to be drawn. Although
site-specific instructions for data collection were
www.ajcconline.org
standardized, interrater reliability was not formally
addressed among all sites. No mechanism was in
place to ensure that ICP was recorded accurately.
For example, we did not record if the transducer
was properly leveled, nor can we Vcdidate that for 2
dyads, ICP was recorded once per minute and CSF
was recorded as "continuous" throughout the 2-hour
observation period. For some interventions, such as
the administration of medications, repositioning of
cervical collar or trachéal tube, and laboratory tests,
the number of observations was small and limited
to few individual dyads, thus limiting application
of those data.
The lack of a standardized approach to ICP
management across the country reduces the general-
izability of the results. In the case of interventions
related to talking to the patient, whether by the
nurse or by the patient's family, the tenor of such
communication is not defined, especially in the
category of "family talking to the patient." Talk may
have been directed at the patient and soothing in
nature, unrelated to the patient and neutral in emo-
tional content, or even loud, angry, or otherwise
potentially stressful to the patient. The various
tones of the verbal communication could have been
responsible for the differing resultant ICP measure-
ments and may have masked true effeas both posi-
tive and negative.
Finally, the heterogeneity of this sample limits
the internal validity. A power analysis was not per-
formed and the small sample size is a limitation.
Although this study yielded more than 3000 min-
utes of data, only 28 nurse-patient dyads were
enrolled. Therefore, subgroup analyses by diagnosis,
method of ICP monitoring, or length of stay before
enrollment could not be performed. Findings must
be validated among a larger cohort.
Conclusion
The change in ICP as a response to nursing
interventions cannot be simplified into a linear rela-
tionship. Any 1 given intervention could precede an
observation during which ICP increases, decreases, or
remains unchanged. Nurses perform a wide variety of
interventions when providing routine care to patients
whose ICP is being monitored. Often intervendons
are performed nearly simultaneously. Only 3 of the
11 interventions, facilitating family members' talking
with the patient, administering sedatives/analgesics,
and repositioning were associated with a significant
decrease in ICP 5 minutes after the intervention.
The lack of a consistent pattern of ICP response
to nursing interventions provides compelling argu-
ments for questioning of conventional wisdom.
vvovw.ajcconline.org A)CC AMERICAN JOURNAL OF CRITICAL CARE, September 2013, Volume 22, No. 5
Interventions conventionally deigned to reduce ICP
(eg, CSF diversion) may not consistently reduce
ICP; and interventions designed to increase ICP
(eg, repositioning) may not result in a consistent
increase. If ICP is to be considered as a variable in
reducing secondary brain injury, some understand-
ing of how ICP changes in response to nursing
interventions is essential. Further research should
be focused on defining a specific context in which a
specific nursing intervendon can be expeaed to affect
ICP in a consistently prediaable manner.
FINANCIAL DISCLOSURES
None reported.
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PNP-BC and Curtis N. Sessler, MD \±¡ CUsstficailons
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