F.N. has ICP monitoring in place with an intraventricular catheter. Nursing interventions
while the catheter is in place include which of the following? Select all that apply.
a. Continuously monitoring the ICP waveforms
b. Using aseptic technique when setting up the device
c. Maintaining a cerebral perfusion pressure of 60 mm Hg
d. Leveling the transducer even with the foramen of Monroe
e. Administering prophylactic antibiotic therapy
f. Notifying the physician if the ICP is greater than 30 mm Hg
a, b, d, e
Examining the ICP waveform can detect a change in the critical relationship between volume
and pressure and allows for early treatment before the onset of clinical manifestations or sustained
elevated ICP. ICP monitoring devices are invasive and carry a risk of infection, hemorrhage, and
obstruction, especially when the device is left in place for longer than 5 days. Aseptic technique must
be maintained at all times. Most surgeons prescribe antibiotics, limit the length of time for which
the ICP monitor remains in place, and monitor cerebrospinal fluid (CSF) samples on a regular basis.
Level the transducer at the tragus of the ear (level with foramen of Monroe). The cerebral perfusion
pressure (CPP) must be maintained near 80 mm Hg to provide adequate blood supply to the brain. If
the CPP drops below this point, ischemia might develop. Normal range of pressure is 3 to 10 mm Hg;
measures to combat ICP need to occur at a pressure of 20 mm Hg, so you would notify the physician
when the pressure is at 20, not 30, mm Hg.
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