Skill 17-4

Caring for a Patient With an External Ventriculostomy (Intraventricular Catheter-Closed Fluid-Filled System)

Intracranial pressure (ICP) is the pressure inside the cranium. The components that occupy the intracranial space, blood, tissue, and cerebrospinal fluid (CSF) circulating in the ventricles and subarachnoid space, contribute to the ICP (Hickey & Strayer, 2020). ICP monitoring is used to assess cerebral perfusion. When ICP increases, as a result of conditions such as a mass (e.g., a tumor), bleeding into the brain or fluid around the brain, or swelling within the brain matter itself, neurologic consequences may range from minor to severe, including death. Normal ICP is less than 15 mm Hg. Elevated ICP, intracranial hypertension, is a sustained ICP of 20 to 25 mm Hg or higher for greater than 5 minutes (Hickey & Strayer, 2020). Box 17-1 identifies signs and symptoms of increased ICP in adults.

An external ventriculostomy is one method used to rapidly reduce ICP and monitor ICP (Hickey & Strayer, 2020; Hinkle et al., 2022). It is part of a system that includes an external drainage system and an external transducer. This device is inserted into a ventricle of the brain, most commonly the nondominant lateral ventricle, through a hole drilled into the skull. The catheter is connected by a fluid-filled system to a transducer, which records the pressure in the form of an electrical impulse (Hinkle et al., 2022). The ventriculostomy can be used to measure the ICP; to drain CSF, such as removing excess fluid associated with hydrocephalus; or to decrease the volume in the cranial vault, thereby decreasing the ICP, and to instill medications. ICP and blood pressure measurements are used to calculate cerebral perfusion pressure (CPP), the blood pressure gradient across the brain and the pressure necessary to maintain an adequate force for blood throughout the brain, to prevent cerebral ischemia (Hickey & Strayer, 2020). ICP monitoring also provides information about intracranial compliance , the ability of the brain to change volume related to a change in pressure; to tolerate stimulation or increase in intracranial volume without an increase in pressure through waveform assessment (Box 17-2) (Hickey & Strayer, 2020; Morton & Fontaine, 2018).

Ventricular drainage is associated with an increased risk of infection. Strict sterile technique should be observed when manipulating the ventricular drain (American Association of Critical-Care Nurses [AACN], 2017; Hickey & Strayer, 2020).

Delegation Considerations

The care of a patient with an external ventriculostomy may not be delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, care for these patients may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Ventriculostomy setup
Carpenter level, bubble-line level, or laser level, according to facility policy
PPE, as indicated

Assessment

Assess the color of the fluid draining from the ventriculostomy. Normal CSF is clear or straw colored. Cloudy CSF may suggest an infection. Red or pink CSF may indicate bleeding. Assess vital signs, because changes in vital signs can reflect a neurologic problem. Assess the patient's pain level. The patient may be experiencing pain at the ventriculostomy insertion site. Assess the insertion site.

Perform a neurologic assessment (see Fundamentals Review 17-2 and Chapter 3). Assess the patient's level of consciousness (LOC). If the patient is awake, assess for their orientation to person, place, and time. If the patient's LOC is decreased, note their ability to respond and to be aroused. Inspect pupil size and response to light. Pupils should be equal and round and should react to light bilaterally. Any changes in LOC or pupillary response may suggest a neurologic problem. If the patient can move their extremities, assess the strength of their hands and feet (see Chapter 3 for detailed instructions on assessing muscle strength). A change in strength or a difference in strength on one side compared with the other may indicate a neurologic problem.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Injury risk
Increased intracranial pressure
Infection risk

Outcome Identification and Planning

The expected outcomes to achieve are that the patient maintains ICP at less than 15 mm Hg and CPP of 50 to 70 mm Hg (adults) (Burns & Delgado, 2019; Hickey & Strayer, 2020; Hinkle et al., 2022; Morton & Fontaine, 2018). Other outcomes that may be appropriate include that the patient is free from infection, and the patient/family/caregivers understand the need for the ventriculostomy.

Implementation

Action	Rationale
1. Review the prescribed interventions and patient health record for specific information about ventriculostomy parameters.	The nurse needs to know the most recent prescribed intervention for the height of the ventriculostomy. For example, if the health care practitioner has ordered that the ventriculostomy is to be at 10 cm, this means the patient's ICP must rise above 10 cm before the ventriculostomy will drain CSF.
2. Gather the necessary supplies.	Preparation promotes efficient time management and an organized approach to the task.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Assemble equipment on the bedside stand, overbed table, or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
6. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
7. Assess the patient for any changes in neurologic status (see Fundamentals Review 17-2 and Chapter 3 for details of assessment).	Patients with ventriculostomies are at risk for problems with the neurologic system.
8. Set the zero reference level. Assess the height of the ventriculostomy system to ensure that the stopcock is at the appropriate reference point: the tragus of the ear (Figure 1), the outer canthus of the patient's eye, or the patient's external auditory canal (Hickey & Strayer, 2020; Munakomi & Das, 2021) using a carpenter level, bubble-line level, or laser level, according to facility policy. Adjust the height of the system, if needed.	For measurements to be accurate, the stopcock must be at a reference point to approximate the catheter tip at the level of the foramen of Monro. Use of the same reference point for all readings is critical to ensure accuracy. Use of a carpenter level, bubble-line level, or laser level, ensures accuracy (Hickey & Strayer, 2020). If the ventriculostomy is used just to measure the ICP and not to drain the CSF, the stopcock will be turned off to the drip chamber.
9. Set the pressure level based on the prescribed pressure. Move the drip chamber to the ordered height. Assess the amount of CSF in the drip chamber if the ventriculostomy is draining.	When the ICP is higher than the prescribed pressure level, CSF will drain into the drip chamber. If the ventriculostomy is to drain CSF, the nurse must turn the stopcock off to the drip chamber to obtain a measurement of ICP. After the ICP value is obtained, remember to turn the stopcock back off to the transducer so that CSF is allowed to drain.
10. Zero the transducer. Turn the stopcock off to the patient. Remove the cap from the transducer, being careful not to touch the end of the cap. Press and hold the calibration button on the monitor until the monitor beeps. Return the cap to the transducer. Turn the stopcock off to the drip chamber to obtain an ICP reading and waveform tracing. After obtaining a reading, turn the stopcock off to the transducer.	The readings would not be considered accurate if the transducer had not been recently zeroed. If the stopcock is not turned off to the patient, when opened to room air, CSF will flow out of the stopcock. The end of the cap must remain sterile to prevent an infection. The stopcock must be off to the drip chamber (open to the transducer) to obtain an ICP. If the ventriculostomy is to drain CSF, the nurse must turn the stopcock off to the drip chamber. After the ICP value is obtained, remember to turn the stopcock back off to the transducer so that CSF is allowed to drain into the drip chamber.
11. Adjust the ventriculostomy height to prevent too much drainage, too little drainage, or inaccurate ICP readings.	If the patient's head is lower than the ventriculostomy, the drainage of CSF will slow or stop. If the patient's head is higher than the ventriculostomy, the drainage of CSF will increase. Any ICP readings taken when the ventriculostomy is not level with the outer canthus of the eye would be inaccurate.
12. Care for the insertion site according to the facility's policy. Maintain the system using strict sterile technique. Assess the site for any signs of infection, such as purulent drainage, redness, or warmth. Ensure the catheter is secured at the site per facility policy. If the catheter is sutured to the scalp, assess integrity of the sutures (Figure 2).	Site care varies, possibly ranging from leaving the site open to air to applying antibiotic ointment and gauze. Sterile technique helps to prevent infection (AACN, 2017; Hickey & Strayer, 2020; Munakomi & Das, 2021). Securing the catheters after insertion prevents dislodgement and breakage of the device.
13. Calculate the CPP, if necessary. Calculate the difference between the systemic MAP and the ICP.	CPP is an estimate of the adequacy of the blood supply to the brain.
14. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
15. Assess ICP, MAP, and CPP continuously or intermittently as prescribed (AACN, 2017). Note drainage amount, color, and clarity.	Frequent assessment provides valuable indicators for identifying subtle trends that may suggest developing problems.
16. Assess ICP drainage system at least every 4 hours, checking the insertion site, all drainage system tubing and parts, for cracks in the system, and for leakage from the insertion site or system. Label the external ventriculostomy tubing and access ports clearly.	Frequent monitoring allows for early identification of problems and prompt intervention. Clear labeling prevents accidental use as an intravenous access.

Evaluation

The expected outcomes have been met when the patient has maintained ICP at less than 15 mm Hg and CPP of 50 to 70 mm Hg (adults) (Burns & Delgado, 2019; Hickey & Strayer, 2020), the patient has remained free from infection, and the patient/family/caregivers have verbalized an understanding of the need for the ventriculostomy.

Documentation

Guidelines

Document the following information: amount and color of CSF, ICP, and CPP; pupil status; motor strength bilaterally; orientation to time, person, and place; LOC; vital signs; pain; assessment of insertion site; and height of the ventriculostomy.

Sample Documentation

11/2/25

1410 External ventriculostomy zeroed; transducer level with outer canthus of eye, drip chamber 10 cm; draining cloudy, straw-colored CSF (12 mL), Dr. Hill notified of clarity. ICP 10 mm Hg; CPP 83 mm Hg, see attached wave tracing. Ventriculostomy insertion site with small amount of serosanguineous drainage; open to air. Strong equal grip bilaterally. Patient awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light 6/4 bilaterally. See graphics for vital signs. Patient denies pain.

—B. Traudes, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

ICP exceeds established parameters: Notify the health care team immediately. If no parameter is specified, notify the health care team if ICP is >20 to 25 mm Hg (Hickey & Strayer, 2020; Morton & Fontaine, 2018).
CSF stops draining: Assess for any kinks or narrowing of the tubing. Assess that all connections on the tubing are well connected and that CSF is not leaking anywhere from the tubing. Assess the height of the system and the height of the drip chamber. If the system is too high, the CSF drainage will taper off. Assess for any liquid on the sheets around the patient's head. If the ventriculostomy has become clogged, the CSF may begin to leak around the insertion site. Assess the patency of the ventriculostomy catheter. Raise and lower the system. If the ventriculostomy catheter is patent, the fluid in the tube will tidal or rise and fall with the position change. If CSF still is not draining, or if you believe that the tube is clogged, notify the primary care provider. The tube may need to be flushed using sterile technique to ensure patency.
Amount of CSF drainage increases: Assess the height of the system and the height of the drip chamber. If the system is too low, the amount of CSF drainage will increase. If CSF continues to drain at an increased amount, notify the primary care provider. The height of the drip chamber may need to be increased.
CSF has changed from clear to cloudy: Notify the health care team immediately. This can signify an infection, and antibiotics may need to be started.
CSF has changed from straw-colored to pink tinged or serosanguineous: Notify the health care team immediately. This can signify bleeding in the ventricles of the brain.
Catheter is accidentally dislodged: Notify the health care team immediately. Put on sterile gloves and cover the insertion site with sterile gauze. Monitor for color and amount of CSF if draining from the site.

Special Considerations

Secure and label the catheters according to facility policy after insertion, and use care when moving patients to prevent dislodgement and breakage of these devices.
Repositioning is important to prevent skin alterations and to decrease the risks associated with immobility. During position changes, clamp the ventriculostomy; after repositioning, maintain the reference level and ensure the system is patent (AACN, 2017). Modest, initial increases in ICP experienced with repositioning quickly return to baseline after repositioning is complete (McNett & Olson, 2013). Turn and position the patient in proper body alignment, avoiding angulation of body parts. Extreme hip flexion or flexion of the upper legs can increase intraabdominal pressure, leading to increased ICP. Maintain the neck in the neutral position at all times to avoid neck vein compression, which can interfere with venous return (Hickey & Strayer, 2020).
Maintain the head of the bed elevated 30 degrees to promote venous return from the brain, depending on prescribed interventions and facility procedure (AACN, 2017; Hickey & Strayer, 2020).
Endotracheal suctioning episodes should be limited to one to two passes of the catheter (Hickey & Strayer, 2020). The ICP increases associated with suctioning, tracheal stimulation, and coughing are modest and transient (McNett & Olson, 2013).
Oral care is a safe intervention; ICP increases experienced with oral care are modest, transient, and resolve quickly when oral care is complete (McNett & Olson, 2013).
Auditory stimulation for critically ill neurologically impaired patients does not increase ICP and is considered a safe intervention (McNett & Olson, 2013).
Drainage should be turned off at the collection chamber before any intervention involving patient movement, such as suctioning, walking, physiotherapy, and repositioning (Humphrey, 2018).
Plan care to avoid grouping activities and procedures known to increase ICP. Bathing, turning, and other routine care often have a cumulative effect to increase ICP when performed in succession. Allow rest periods between procedures and carefully assess the patient's response to interventions (Hickey & Strayer, 2020).

EVIDENCE FOR PRACTICE

Clinical Practice Guideline: Universal Standard for External Ventricular Drain Care

Hepburn-Smith, M., Dynkevich, I., Spektor, M., Lord, A., Czeisler, B., & Lewis, A. (2016). Establishment of an external ventricular drain best practice guideline: The quest for a comprehensive, universal standard for external ventricular drain care. Journal of Neuroscience Nursing, 48(1), 54-65.

An interdisciplinary team of nurses, advanced practice nurses, and neurointensivists reviewed medical and nursing literature as well as research-based institutional protocols on external ventricular drain (EVD) insertion and maintenance to determine global best practices. The resulting guideline addresses preinsertion hair removal and skin preparation, aseptic technique, catheter selection, monitoring of EVD insertion technique using a bundle approach, postinsertion dressing type and frequency of dressing changes, techniques for maintenance and CSF sampling, duration of catheter placement, and staff education/competence, and surveillance.

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Skill 17-4

EVIDENCE FOR PRACTICE