Recognising Raised Intracranial Pressure for Student Nurses
Learn how neurological deterioration may indicate increasing intracranial pressure and which changes should trigger urgent assessment and escalation.
What is raised intracranial pressure?
The skull contains brain tissue, blood and cerebrospinal fluid within a fixed space. Changes that increase the volume of one of these components can increase pressure within the skull.
Swelling
Cerebral oedema associated with injury or illness can contribute to increased intracranial pressure.
Bleeding
Intracranial bleeding can occupy additional space and contribute to neurological deterioration.
Fluid accumulation
Disturbance to cerebrospinal fluid circulation or drainage may also increase pressure.
Why does this matter?
Rising pressure can compromise normal brain function and cerebral perfusion. Recognition of neurological deterioration is therefore critical.
Possible warning signs
Presentation depends on the underlying cause and severity. No single symptom should be interpreted in isolation.
Increasing drowsiness
A patient may become less alert, confused or increasingly difficult to rouse.
New or worsening pain
Headache may occur, particularly when associated with other new neurological findings.
Nausea or vomiting
New vomiting alongside neurological deterioration may be clinically significant.
Pupillary change
New changes in pupil size, symmetry or reaction require appropriate neurological assessment.
New weakness
New limb weakness or other focal neurological abnormalities may indicate significant neurological change.
Seizure activity
New seizure activity may accompany acute intracranial pathology and requires urgent assessment.
Changes in consciousness are particularly important
A deteriorating level of consciousness can be one of the most important signs of neurological deterioration.
Know what is normal
Understand the patient's previous level of alertness and responsiveness.
Notice deterioration
Increasing confusion, drowsiness or difficulty waking the patient should prompt reassessment.
Repeated assessment matters
A progressive change may be more informative than one isolated neurological observation.
Observe more than consciousness alone
- Level of consciousness and responsiveness.
- New confusion or behavioural change.
- Pupil size, symmetry and response according to local practice.
- New limb weakness or asymmetry.
- Speech or communication changes.
- New seizure activity.
- Headache or worsening headache.
- Nausea or vomiting.
- Changes in respiratory pattern.
- Changes in cardiovascular observations.
Documenting what has changed and when it changed is often more useful than simply recording that a patient appears “drowsy”.
Neurological deterioration still requires ABCDE
Airway
Reduced consciousness can threaten airway protection. Assess airway patency and escalate concerns immediately.
Breathing
Assess respiratory rate, pattern, oxygen saturation and any change in breathing.
Circulation
Assess pulse, blood pressure, perfusion and cardiovascular trends.
Disability
Assess consciousness, pupils, neurological changes and blood glucose according to local practice.
Exposure
Look for injuries, signs of infection or other clues to the cause of deterioration.
Escalate
New or progressive neurological deterioration requires urgent clinical review.
Do not wait for dramatic cardiovascular changes
Severe intracranial hypertension can eventually produce major changes in consciousness, breathing and cardiovascular observations. These are concerning late features rather than signs to wait for before acting.
Marked deterioration
The patient may become profoundly drowsy or unresponsive.
Abnormal pattern
Significant neurological deterioration may alter respiratory pattern or effectiveness.
Cardiovascular changes
Significant changes in blood pressure and pulse may occur in severe deterioration.
When might raised intracranial pressure be a concern?
Increased intracranial pressure is not a diagnosis a student nurse should make from symptoms alone. However, recognising higher-risk clinical contexts can help you identify deterioration.
Head injury
Neurological deterioration following head trauma requires urgent assessment.
Intracranial bleeding
Bleeding within the skull can cause neurological deterioration and increased intracranial pressure.
Swelling or obstruction
Other intracranial conditions may cause swelling or interfere with normal cerebrospinal fluid dynamics.
Putting neurological trends together
Example
A patient admitted following a head injury was alert and speaking normally at the beginning of your observations.
They later report worsening headache and vomit. When you reassess them, they are noticeably more drowsy and require repeated prompting to answer questions.
Rather than considering each feature separately, you recognise the pattern: head injury + worsening headache + vomiting + deteriorating consciousness.
You immediately call for appropriate clinical assistance while reassessing the patient using ABCDE and communicating the neurological change clearly.
High-concern neurological changes
- Progressively reduced consciousness.
- New difficulty waking the patient.
- New pupil abnormality.
- New focal weakness or neurological deficit.
- Repeated vomiting with neurological change.
- New seizure activity.
- Significant change in respiratory pattern.
- Rapid neurological deterioration following head injury.
- Any neurological change that is rapidly progressing.
Describe exactly what has changed
Example escalation
“I'm concerned about Mr Patel following his head injury. At 14:00 he was alert and speaking normally. He has now vomited twice and is increasingly drowsy. He needs repeated prompting to respond, which is a clear change from his previous neurological assessment.”
This communicates the baseline, change, timing and deterioration rather than simply saying that the patient “looks worse”.
Recognition errors to avoid
- Dismissing increasing drowsiness as tiredness.
- Looking only at NEWS2 and overlooking neurological change.
- Failing to compare with the patient's previous neurological state.
- Waiting for dramatic late signs before escalating.
- Ignoring repeated vomiting after neurological injury.
- Recording “confused” without describing the actual change.
- Focusing on diagnosis instead of recognising deterioration.
- Failing to repeat neurological observations when the patient changes.
Recognise → assess → communicate → escalate
Spot neurological change
Notice worsening consciousness, pupils, movement, seizures, headache or vomiting.
Compare and reassess
Use ABCDE and focused neurological observations while comparing findings with the patient's previous state.
Report the trend
Communicate exactly what has changed, when it changed and how the patient is deteriorating.
Keep building your neurological assessment skills
Recognising changes from a patient's neurological baseline and describing those changes clearly can make a major difference when deterioration develops.
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