Raised intracranial pressure on the ward and after head injury or brain surgery: signs, positioning, what to avoid
- Assessment
On the ward, the nurse spots rising pressure in the skull early (less alert, headache, vomiting, a pupil change) and calls at once.
What it is
Pressure inside the skull rises when something takes up space (bleeding, a tumour, swelling, extra cerebrospinal fluid). On a ward, the patients at risk are those with a head injury, a bleed, a stroke, a brain tumour, an infection such as meningitis, or a recent brain operation. The nurse's job on the ward is recognition and escalation: compare each neuro check with the last one, look for the early signs (behaviour change, less alertness, headache, vomiting, new weakness or vision change) and call at once when they appear. Sudden raised pressure is an emergency, and its treatment happens in intensive care; ICP monitoring and the ICU measures have their own pages. On the ward, positioning the head and teaching after brain surgery are the main nursing measures.
Reference values
- Baseline: the patient's own level of consciousness, Glasgow score, pupils and limb strength at admission or after surgery; every later check is compared with it.
- Normal pupils: equal, round and reactive to light (see neuro checks).
- Causes to have in mind: head injury, subdural or epidural haematoma, brain bleed, stroke, tumour, meningitis or encephalitis, hydrocephalus, seizure.
- After brain surgery, call for: fever of 38.3 °C or higher, a wound that is red, swollen, draining or opening, a headache that does not ease, more sleepiness or confusion, new weakness or speech trouble, a seizure, or fluid dripping into the throat.
What you need
- Neuro-check chart with the baseline recorded.
- Pupil torch, vital-signs monitor and pulse oximeter.
- Suction and oxygen at the bedside; seizure precautions if ordered.
How to measure it (and why)
- Record a full baseline (consciousness, Glasgow, pupils, limbs, vital signs): change can only be seen against it.
- Repeat neuro checks at the ordered interval and compare with the last: a fall in alertness is the earliest sign.
- Ask about headache and vomiting, and look for new weakness, numbness or vision change: they point to rising pressure.
- Check the pupils for size, equality and light reaction: a pupil that becomes larger or slower is an alarm.
- Keep the head of the bed at 30° and the head in line with the body, unless ordered otherwise: this is the recommended position when pressure may be raised.
- Keep the airway clear and the oxygen saturation in the ordered range: safe oxygen levels limit secondary brain injury.
- Check temperature and glucose at the set times and report high values: fever and glucose control are part of protecting the injured brain.
- After brain surgery, check the wound and drains and teach: no bending at the waist or heavy lifting, head raised to sleep, no new medicines without the surgeon.
How to read it
- A drop of even one point in the Glasgow score, new confusion or restlessness is a change, not "tiredness".
- Headache with vomiting and falling alertness after a head injury may mean a growing blood clot: this is an emergency.
- Any change in pulse, blood pressure or breathing pattern in a patient at risk is reported at once; the ICU page on raised intracranial pressure covers what follows.
- Fluid or blood dripping into the throat after brain surgery is reported to the surgeon.
Next step: when to call for help
- Call at once (rapid-response team): fall in Glasgow score, new confusion, restlessness or agitation, difficulty waking the patient.
- Call at once: one pupil larger or slower than the other, new weakness, slurred speech, a seizure, repeated vomiting.
- Call at once: headache that keeps getting worse, a change in pulse, blood pressure or breathing pattern.
- Report in the same shift: fever, wound redness or discharge, fluid dripping into the throat, swelling under the scalp that grows or lasts more than 2 weeks.
Test yourself
Think of the answer, then tap the question to see it.
What is usually the earliest sign of rising intracranial pressure?
A change in level of consciousness: new confusion, restlessness, drowsiness or behaviour change, seen against the patient's baseline.
How is the head positioned when there is risk of raised intracranial pressure?
Head of the bed at 30°, with the head in line with the body, unless the team orders otherwise.
After a head injury, which signs need emergency care?
A headache that keeps getting worse, repeated vomiting, one larger pupil, slurred speech, weakness, seizures, increasing confusion, or being unable to wake.
Which teaching points apply after brain surgery?
Sleep with the head raised, do not bend at the waist or lift heavy loads, take only the medicines the surgeon approves, and report fever, wound changes, worse headache or new weakness.
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Increased intracranial pressure (Medical Encyclopedia) (MedlinePlus, U.S. National Library of Medicine, 2024); Signs and symptoms of traumatic brain injury (TBI) (Centers for Disease Control and Prevention (CDC), 2024); Brain surgery - discharge (MedlinePlus, U.S. National Library of Medicine, 2024); Best evidence summary on positioning management in stroke patients (Frontiers in Neurology (Xiong Y et al.), PubMed Central, 2025).
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