Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
신경외과 강의 과정 두개강 내압 아주대학교병원 윤 수한 Department of Nursing (UCSF) Training Programs • Acute Care Training Program (ACTP) • Adult Critical Care Training Program (CCTP) • Pediatric Critical Care / Pediatric Acute Care Training Program (PCCTP/PACTP) • Emergency Department Training Program (EDTP) 내용 1. 두개강 내압에 관여하는 두개강의 구조적 특징 2. 두개강내 용적과 압력과의 관계 3. 두개강 내압과 뇌혈류와의 관계 4. 정상 두개강 내압의 범위와 체위에 따른 변화 5. 두개강 내압의 측정방법과 그 장단점 6. 두개강 내압항진에 의한 뇌기능장애와 생체징후에 대한 영향 7. 두개강 내압항진의 치료 8. 두개강 내압 항진에 의한 뇌탈출 Fall 2001 UNIVERSITY OF TEXAS SAN ANTONIO SCHOOL OF NURSING OBJECTIVES: Neuroscience Nursing 1) Explain the Monro-Kellie Hypothesis. 2) Interpret a Volume-Pressure Curve. 3) State the normal intracranial pressure. 4) Define compliance. 5) Relate the concepts of cerebral blood flow and cerebral perfusion pressure to clinical appearance. 6) Distinguish between three types of cerebral edema. 7) Describe the clinical signs associated with an increase in intracranial pressure. 8) Differentiate between the types of cerebral herniation. 9) Discuss the nursing care of increased intracranial pressure, with particular emphasis on drug therapy. 10) Review four types of intracranial monitoring systems. 11) Develop a comprehensive nursing care plan for the patient with increased intracranial pressure. 두개강내 구조물 1. 두개강내 혈액량 • 호흡저하 PaCO2 증가 또는 PaO2 감소 뇌혈관 확장 • 정맥 폐색 정맥 울혈 ( valve가 없음) 뇌척수액 분비와 흡수 • 분비 – choroid plexus, ependymal cells of ventricle • 흡수 – arachnoid villi, blood vessels, cranial nerves via lymphatic channel 뇌척수액 순환 두개강내 용적 • 뇌척수액 10 % • 두개강내 혈액 4-10 % 뇌부종 저산소증, CO 종양 Vasogenic edema Cytotoxic Edema Hydrocephalic (Interstitial) Edema Monroe Kellie의 가설 두개강내 뇌척수액 두개골 두개골은 뇌, 혈액, 그리고 뇌척수액으로 이루어진 한정된 공간이므로, 이들 중 한가지의 용적증가는 두개강내 압력을 척수강 증가시키고 나머지 두가지의 용적의 감소를 초래한다. 두개강 내압 (mmHg) 비정상적 종괴 병변 (공간점유 병변) • 종양, 혈액 뇌부종 • Pus, etc 정상 뇌구조의 이동 두개강 내압항진 용적 적응의 한계 압력 동맥 • 적응 한계점에 뇌척수액 이르면 (두개강 정맥 내압 위기), 적은 용적증가에 의해서 높은 압력 상승이 일어난다. 변이 용적 뇌압증가의 역동적 변화 병변크기 증가 국소적 압력증가 국소적 뇌부종 국소적 뇌 이동 뇌척수액 통로 폐색 수두증 미만성 뇌압 증가 중뇌 및 소뇌 탈출 전반적 뇌 저산소증 뇌간 출혈 및 허혈 뇌혈류 단절 사망 뇌혈류 변화 (blood pressure, PaCO2 and PaO2) 뇌혈류 ml/100mg/min 압력 자기조절(Autoregulation) 1) 혈압성 자기조절 (Pressure autoregulation) 2) 대사성 자기조절 (Metabolic autoregulation) ① 저산소증 (Hypoxemia) ② 고이산화탄소증 (Hypercarbia) ③ 산도 (pH) 혈압성 자기조절 (Pressure autoregulation) 전신동맥압이 50 ~ 160 mmHg 일 경우에 뇌혈류의 혈압성 자기조절기능이 가능하다. 대사성 자기조절 (Metabolic autoregulation) 뇌에서 대사정도와 혈류의 양은 정확히 비례한다. 기전 : 1) 저산소증 (Hypoxia) 2) 고이산화탄소증 (Hypercarbia) 3) 산도 (pH -- ECF lactic acidosis) 4) Increased depolarization-- Increased ECF potassium 5) Adenosine : a potent cerebral vasodilator 저산소증 (Hypoxia) 저산소증은 뇌혈관 확장을 초래한다 1) chemoreceptor in the aortic arch & carotid body 2) stimulation of locus ceruleus 3) chemical regulation through alteration of ECF composition 고이산화탄소증 (Hypercarbia) PaCO2 증가 혈관 확장 저이산화탄소증 후 정상 이산화탄소증 (Normocarbia after hypocarbia) 뇌혈관근 마비 (Cerebral Vasomotor Paralysis) When ICP approaches the systemic pressure, cerebral vessels no longer respond to changes in carbon dioxide tension. luxury perfusion: The amount of blood flowing through the tissue is in exess of metabolic needs and does not imply a particular state of responsiveness of the vessels. CPP, ICP, BP and CBF Cerebral perfusion pressure (CPP) = arterial inflow pressure - venous outflow pressure = mean arterial pressure ( MAP ) - ICP CBF = CPP / CVR = ( MAP- ICP ) / CVR ICP = Volume, Brain, Elastance(inverse of compliance) : Brain, Blood, CSF, Mass Cerebral perfusion pressure • 100mmHg in normal • 40 mmHg (Critical level) > --> cerebral hypoxia in animal • 60 mmHg < tolerable in normal condition • 80-90 mmHg < ideal in ischemic condition Normal ICP • 100 - 180 mmH2O (1015mmHg) : measured from lumbar puncture in lateral decubitus position • Posture dependent, pulsatile • Newborn 0.7 - 1.5mm Hg • Infant 1.5 - 6.0 mm Hg • Children 3.0 - 7.5 mmHg. Indications for ICP monitoring Injury Risk of raised ICP Severe Head Injury (GCS 3-8) Abnormal CT scan 50-60% Normal CT Scan with Age > 40 or BP < 50-60% 90mmHg or abnormal motor posturing Normal CT scan with No risk factors 13% Moderate Head Injury (GCS 9-12) •If anaesthetised/sedated •Abnormal CT scan approx. 10-20% will deteriorate to severe head injury Mild Head Injury (GCS 13-15) •few indications for ICP measurement Only 3% will deteriorate Methods of measurement 1 - Spinal tap Spinal tapping in Brain Herniation contraindicated in IICP due to space occupying lesion can be performed by experienced hands in IICP without brain shift ex) Encephalitis, Meningitis, Pseudotumor cerebri, Hydrocephalus, etc. Methods of measurement 2 - Ventricular puncture - Transducer : 1) epidural 2) subdural 3) subarachnoid 4) intraparenchymal Intracranial Pressure Monitoring Devices I Intracranial Pressure Monitoring Devices II Epidural catheter Lower risk of infection No transducer adjustment with head movement Unable to recalibrate or zero after placement. Decreased accuracy sensing through dura. Unable to drain CSF Subarach noid bolt /screw No penetration of brain Decreased risk of infection. Able to sample CSF. Direct pressure measurement Unable to drain CSF Requires intact skull Transducer repositioning with head movement High pressure may cause herniation of brain tissue into bolt Ventriculo stomy catheter CSF drainage and sampling Direct measurement of pressure Risk of intracerebral bleeding or edema along cannula track. High risk for infection. Transducer repositioning with head movement Fiberoptic catheter Versatile, placed in ventricle or subarachnoid space No adjustment of transducer with head movement Separate monitoring system required Catheter relatively fragile Unable to recalibrate or rezero after placement Ultrasonic pulsed-phase locked loop (PPLL) device Normal Pressure Waves •P1 (percussion wave) represents arterial pulsations •P2 (rebound wave) reflects intracranial compliance •P3 (dichrotic wave) represents venous pulsations Abnormal Pressure Waves Pathologic Pressure Waves(I) A wave type 1 : rhythmic fluctuations in 15 to 30 minutes intervals type 2 : plateau wave – pressure up to 60 to 100 mm Hg – duration from 5 to 20 minutes – regular or irregular frequency – frequently with pressure Sx and worsening of neurologic deficit Pathologic Pressure Waves(II) mmHg B wave minutes • one per minute waves • found in association with Cheyne-Stokes respiration • postulated to be result of common brain stem rhythm altering both respiratory and vasomotor tone Pathologic Pressure Waves(III) C wave mmHg minutes • six per minute waves • associated with Traube-Hering-Mayer blood pressure waves • postulated to be result of common brain stem rhythm altering both blood pressure and cerebral vasomotor tone Maintenance of ICP monitoring • All monitors have a risk of infection. 1) Infectious risk increases with duration of monitoring, particularly after the 5 th day. 2) The site of monitoring is typically changed every 5-7 days. 3) Prophylactic antibiotics (Ancef) are indicated for the duration of ICP monitoring. • An arterial line is indicated in all patients with an ICP monitor Complications of Ventriculostomy • Ventriculostomy associated haematomas: About 1.1% • Bacterial infection/colonisation: About 5% • Malfunction/obstruction: About 6% • Malposition: About 3% Clinical Aspect of IICP 1) Focal CNS signs 2) IICPsigns 3) Brain shift and herniation signs Symptoms Infants: • bulging fontanelle • separated sutures Older children and adults: • vomiting • headache • change in behavior • progressivedecreased consciousness, may become coma • seizures Cushing’s Reflex Said to be the the last compensatory mechanism before herniation Signs: 1) Increased ICP 2) Widened Pulse Pressure (increased SBP & decreased DBP) 3) Bradycardia IICP Sx & Signs 1 Headache ( V, IX, X, C2, 3 ) Non-specific in character, intensity, and distribution from 1) venous dilataton 2) traction on bridging cerebral vein 3) stretching of arteries at the base Morning headache • With brain swelling from vascular dilatation and edema secondary to CO2 retension during sleep. • Aggrevated by coughing, stooping down. • Terminated by vomiting accompanied with hyperventilation IICP Sx & Signs 2 Vomiting - Due to IICP - Due to local lesion in the fourth ventricle IICP Sx & Signs 3 Papilledema • Optic nerve : An extension of brain, complete with meningeal coverings and subarachnoid space. • Edema of nerve head and engorged retinal veins. • Some days need to develop. • Seldom in infants • Less of ten in the elderly. Optic atrophy papilledema Normal IICP Sx & Signs 4 Mental Changes • from 1) direct compression to mid brain 2) caudal displacement and distortion of brain stem • - Alert(Clear), Drowsy, Stuporous, Semicoma, Coma • Glasgow coma scale • Sixth nerve palsies can occur due to stretching of nerve by caudal displacement of the brain stem, but not common. Vasodilatation cascade model Vasoconstriction cascade model Brain herniations • IICP in only one compartment squeeze brain toward lower pressure area. • Transfalxial/subfalxial herniation • Transtentorial herniation (tentorial, temporal, or uncal cone/herniation) • Transforaminal herniation (tonsilar or cerebellar cone/herniation) • Upward (transtentorial) herniation 1. Transtentorial herniation(I) : Herniation of uncus and hippocampus via tentorial incisure - Ipsilateral 3rd nerve palsy : 1) direct compression 2) mid brain ischemia 3) compressed by petroclival ligament 4) compression or distortion on entering cavernous sinus 5) kinked across displaced PCA or trapped between PCA & SCA - Hemianopic defect or intermittent total blindness by 1) obstruction of PCA 2) compression of optic tract 1. Transtentorial herniation(II) - Pressure on midbrain --- intermittent decerebration - Mental change : due to reticular formation dysfunction - Contralateral hemiparesis : due to compression of cerebral peduncle - Ipsilateral hemiparesis Kernohan notch pressure of the free edge of the tentorium against the opposite cerebral peduncle - Bradycardia - High blood pressure - Decorticate rigidity - Decerebrate rigidity : Transection of midbrain 2. Foraminal herniation Herniation of cerebellar tonsil via foramen magnum • Abnormal neck posture • Stiff neck • Abnormalities of respiratory rate and rhythm : - Cheyne-Stokes breathing - a crescendo of breathings of increasing depth and frequency followed by a period of total apnea of up to a minute or so. - Apnea is frequently sudden without impaired consciousness or any other warning signs Tentorial Herniation Site Structure Signs Lateral(Uncal) Oculomotor Cbr. peducle Post Cbr Art Ptosis, mydriasis, lat. deviation Hemiparesis hemianpsia Post(Tectal) Quadrigeminal plate Bilat. Ptosis Upward gaze paralysis Central(Axial) Reticular formation Cortospinal tr. Midbrain and pons Depression of consciousness Decerebrate rigidity Impairment of eye reflex Irregular respiration Arterial hypertension Bradycardia Irregular respiration Subfalcine and tonsilar Herniation Site Subfalcine (Cingulate) Structure Signs Singulate gyrus Leg weakness Ant. Cbr. Art Tonsilar(Foramial) Medulla Sudden apnes IICP Management (1) 1. Removal of causes • Mass : Removal of Hematoma, Tumor, Abscess, etc. • Hydrocephalus : Removal of CSF - Permanent shunt, Intermittent drainaged by lumbar puncture • Edema : Steroid • Cerebrovascular dilatation : Hyperventilation 2. Reduction of brain bulk • Dehydrating agents : Hyperosmotic agents - Mannitol, Urea, Glycerol • Diuretics - Lasix IICP Management (2) 3. Reduction of CBV • PCO2 (25-35mmHg) : Hyperventilation • Sedation : muscle relaxant, Barbiturate coma, Isoflurane • Hypothermia with antipyretics, or with active cooler down to 33-35C 4. Surgical Decompression • Ventriculostomy (EVD) • Craniectomy • Extension duroplasty • Lobectomy: fronatal, temporal • Cbll lobectomy for cbll infarction Sedation for ICP • Sedation using Versed or Ativan 0.1 mg/kg IV or 0.1 mg/kg/hour continuous infusion. • Additional sedation and/or analgesia should be considered before suctioning, patient transfer, procedures, etc. • In addition Lidocaine 1 mg/kg iv before suctioning may blunt the increased ICP associated with this intervention. • Neuromuscular blockade can be considered to decrease any muscle movement (coughing, shivering, etc.) that might contribute to increased ICP. Head position • Elevation of the head of the bed 15-30 degrees or no elevation • Keeping the head midline Mannitol • Decreases blood viscosity resulting in lower cerebrovascular resistance, reflex cerebral vasoconstriction and reduction in cerebral blood volume. • May act as an osmotic agent to decrease brain water with subsequent osmotic diuresis. • Dose is 0.25-0.5 gm/kg rapid IVP over ~ 5 min. • Goal: reduction in ICP, improvement in CPP or maximum osmolality of 310-320. If multiple doses are administered, the patient can be placed on scheduled mannitol Q4-6 hours. Serum osm and Na are followed at a similar interval and mannitol is withheld if the osm are >310. Na typically are in the 150s. Hyperventilation • Hyperventilation causes cerebral arterial constriction with subsequent decreased cerebral blood flow and decreased ICP. • It is a potentially harmful method of decreasing ICP as CPP may concomitantly be compromised. • Moderate HV to a PCO2 of 30-35 is typically well tolerated. More extreme hyperventilation is no longer practiced at most trauma centers. • The beneficial effects of HV diminish after 24-48 hours, due to buffering, however rapid reversal of HV results in rebound increased ICP. Thus it is important that HV is weaned slowly (ie. over hours to days). Barbiturate coma • Employed for increased ICP unresponsive to less invasive therapies. • Dose is 5 mg/kg bolus every hour X 3 and an infusion of 1-5 mg/kg/hour titrated up or down to achieve control of intracranial hypertension or to achieve burst suppression (2-9 bursts/minute on EEG), whichever comes first. Continuous EEG monitoring is necessary until burst suppression is achieved, intermittant monitoring may be appropriate once the patient has stabilized. • Hypotension due to cardiac depression is common and patients frequently require vasopressor support with epinephrine or norepinephrine. It is prudent to have vasopressor medications at the bedside before loading with pentobarb. A pulmonary artery catheter should be considered to guide management. Hypothermia • Mild vs moderate • Short vs long term • Early vs late • With or without barbiturate • Morbidity and mortality External Ventricular Drain • Br J Neurosurg 2001 Aug • Department of Neurosurgery, University of Illinois at Chicago • 103 consecutive cases • The average duration of EVD was 10.7 days (range 1-28 days). • Complications • one case of positive cerebrospinal fluid (CSF) culture • one small intraparenchymal hematoma • two cases of EVD disconnection Decompressive craniectomy • High IICP: 30 vs 40 vs 50 • Craniectomy only vs CR + duroplasty vs CR+ duroplasty + lobectomy • Frontal lobectomy vs temporal lobectomy • Morbidity: functional grade (ADL grade) • Mortality: Survival Nursing protocol of Victoria Hospital, London 1) 2) 3) 4) 5) 6) 7) 8) 9) Nurse:patient ratio of 1:1 Neurological assessment of vital signs a minimum of q.1.h I.C.P. measurements recorded not less than q1h, Loss of wave requires notification of the CCTC and neurosurgery resident, if flushing the transducer and pressure tubing does not correct the problem. The flush devise provides extra security against accidental flushing. An order MUST BE written to identify at which level the drainage bag is to be placed Maintain good neck alignment with head of bed elevated 30. Maintain as quiet an environment as possible Temperature will be measured q2h by a core method (ie., pulmonary artery.) If a cooling blanket is in use, temperatures will be measured q1h. NIH Clinical Center Nursing Department Care of the Patient with an Intracranial Pressure (ICP) Monitoring Device 1. Assessment (I) 1. 2. Neurological Assessment to include Glasgow Coma Scale and: 1) level of consciousness and mental status 2) pupil size and shape and light response 3) extraocular movements and visual acuity 4) motor movement 5) extremity strength 6) headache, nausea, & vomiting 7) fontanels, cranial sutures, & head circumference for pediatric patients < 2 years 8) seizure activity ICP (normal adults < 10 - 15 mm Hg, pediatric patients: Newborn 0.7 - 1.5mm Hg, Infant 1.5 - 6.0 mm Hg, Children 3.0 - 7.5 mmHg. NIH Clinical Center Nursing Department 1. Assessment (II) 3. Cerebral Perfusion Pressure (CPP) (MAP - ICP; normal 70-100 mm. Hg; normal CPP in pediatric patients is variable and dependent upon the age-related MAP but should be at least 40-60 mmHg.). 4. Changes in ICP waveform 5. Catheter insertion site to include:CSF leakage 6. 1. Bleeding 2. Swelling and inflammation 3. Integrity of dressing Cerebral Spinal Fluid (CSF) output to include: 1. Color 2. Amount 3. Clarity NIH Clinical Center Nursing Department 1. Assessment (III) 7. Patency of system and height of collection chamber or transducer (if applicable to system) 8. Changes in ICP related to turning, head position, crying, coughing, and environmental stimuli. 9. Vital signs including any widening of pulse pressure. 10. Ventilatory status to include: a. Oxygen saturation b. Rate, depth, & changing pattern of respirations c. pH and pCO2 (when ordered) 11. Hydration status to include: 1) Urine & output, urine specific gravity 2) skin turgor 3) serum osmolality 4) Pulmonary Capillary Wedge Pressure (PCWP) (when ordered) 5) Central Venous Pressure (CVP) (when ordered) NIH Clinical Center Nursing Department Interventions (I) 1. Verify physician’s orders for hourly ventricular drainage parameters. 2. Maintain head of bed flat or raised to a prescribed height as ordered or depending on ICP and CPP measurements. Clarify head position with physician. 3. Maintain head and neck in neutral position. Avoid hyperflexion, hyperextension, or severe rotation. 4. Verify the physician’s order for insertion site dressing changes. 5. Maintain integrity as a closed system. 6. Inspect the system for kinks and leaks in the circuit. 7. Change drainage bag when the drainage bag is 3/4 full or in place for 72 hours (verify with neurosurgeon). Mark drainage bag with time and date. Maintain aseptic technique. For breaks in the sterile system, notify MD. NIH Clinical Center Nursing Department Interventions (II) 8. Zero balance and calibrate the system at least q 8 hr. and prn. 9. Set ICP alarms 10 mm Hg lower and higher than the patient’s usual range. 10. Secure endotracheal tubes in ways that do not occlude venous return to the head. 11. Suction patients for less than 10 seconds. If coughing occurs, consider administering lidocaine via the endotracheal tube per MD order. 12. Space activities of daily living. 13. Decrease environmental stimuli. 14. Provide cooling measures to maintain normal body temperature. 15. Administer stool softener as per physician order to prevent constipation and straining. NIH Clinical Center Nursing Department Interventions (III) 16. Notify physician for: 1) Any changes in neurological signs 2) Elevated ICP and/or values greater than 15 mm Hg. for 5 minutes or more 3) CPP greater than 100 mm Hg. or less than 70 mm Hg. 4) Temperature or WBC elevation 5) CSF leakage 6) Change in CSF drainage amount, color and clarity 7) Malfunction of the monitoring system. NIH Clinical Center Nursing Department Interventions (IV) 17. Troubleshoot the ICP fluid filled system for problems such as: 1. Breaks in the system 2. Dampened waveform 3. Loss of wave form 4. Occlusion of tubing 5. Change in CSF drainage amount 18. Administer sedation per MD order 19. Minimize any increases in intra-abdominal/intrathoracic pressure (an increase in intra-abdominal pressure may require gastric decompression) NIH Clinical Center Nursing Department Patient and Family Education 1. Teach regarding the need and rationale to maintain specific head position. 2. Teach regarding the effects of environmental stimuli on ICP. 3. Discuss family’s role in controlling environmental stimuli. NIH Clinical Center Nursing Department Documentation 1. Document hourly on the approved Critical Care Flow Sheet. 2. Document all nursing assessments and interventions. JASTREMSKI CA, College of Nursing, State University of New York Health Science Center Controlling ICP: The nurse’s role • Respiratory support – When suctioning is warranted, do so for no more than 10 seconds at a time, providing several breaths of 100% O2 between passes. – Hyperventilating the patient for about a minute before and after the procedure will also help reduce the rise in ICP. – As soon as you remove the suction catheter, hyperinflate the lungs with 100% O 2. • Patient positioning – To avoid neck flexion, make sure the patient’s head and neck are aligned with the rest of his body. – When repositioning the patient, use the log roll technique to help avert neck flexion. – Position the head of the bed at 30 degrees or in the flat position • Environmental support – Keep loud noises, painful procedures, bright lights, and other noxious stimuli to a minimum; they, too, increase ICP. – To create a comfortable, familiar environment – Offer soothing, caring touch. It can help decrease ICP. Perdue Law Firm Houston, TX Nursing negligence • A girl born with hydrocephalus (water on the brain) is treated successfully with a shunt. • Twelve years later it becomes necessary to lengthen the shunt. Following the operative procedure the shunt becomes kinked. • This causes the cerebral spinal fluid to press on the brain. Despite signs of intracranial pressure, the nurse caring for the girl in the post-surgical unit fails to alert the surgeon. • The child experiences brain damage. Summary • Intracranial volume and pressure • ICP vs CBF • ICP : normal range • ICP difference on position change • IICP and Symptoms • Treatment of IICP NIH Clinical Center Nursing Department Care of the Patient Receiving a Continuous Intracranial Infusion: I. Assessment 1) The patient's neurological status and vital signs will be assessed every hour. The minimal neurological assessment will include: ① ② ③ 2) 3) Level of consciousness and mental status Cranial nerves 2, 3, 4, 5, 6, 7 Motor power The patient's head dressing will be assessed every hour. The nurse will inspect the pump and infusion system every 1 hour for: ① ② ③ ④ ntegrity of the catheter and infusion tubing. Bleeding or drainage at the catheter site. Infusion rate and volume infused as per physician order Absence of tension on catheter and tubing. NIH Clinical Center Nursing Department II. Interventions 1) The nurse may reinforce a loose dressing. Complete dressing change will be performed by the physician. 2) Instruct the patient regarding the symptoms of increased intracranial pressure. 3) The nurse will instruct the patient to : ① Avoid touching the dressing, infusion tubing, and pump. ② Call the nurse if the alarm sounds. ③ Call the nurse if any leakage, bleeding or drainage is noted. ④ Call the nurse for symptoms of increased intracranial pressure. 4) Monitor Intake and Output throughout the infusion. Record hourly and cumulative infusion volumes. NIH Clinical Center Nursing Department III. Documentation 1) The patient's neurological status will be documented in the MIS every 4 hours. 2) The condition of the infusion site and system will be documented every 4 hours. 3) Document intake and output including hourly infusion amounts in the MIS. 4) All dressing changes will be documented. 5) Document the start and end of each infusion under "Scheduled/Miscellaneous Medications" in the MIS. AANN Clinical Guideline Policies and Goals • ICP Monitor Placement – Types of Devices – Patient Preparation – Monitor Placement • Post Placement Management of Fluid Filled and Fiberoptic Systems – Patient Assessment – Patient Care – System Maintenance • Trouble Shooting for Fluid Filled and Fiberoptic Systems – Patient/Family Education – Documentation – Removal of the Monitor