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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Adaptive Capacity Decreased: Intracranial - Increased Intracranial Pressure; Altered Level of Consciousness
Linda Arsenault, RN, MSN, CNRN
Michele Knoll Puzas, RNC, MHPE

NANDA: A clinical state in which intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure in response to a variety of noxious and non-noxious stimuli

Intracranial pressure (ICP) reflects the pressure exerted by the intracranial components of blood, brain, and cerebrospinal fluid (CSF), each ordinarily remaining at a constant volume within the rigid skull structure. Any additional fluid or mass (subdural hematoma, tumor, abscess, or others) increases the pressure within the cranial vault. Because the total volume cannot change (Monro-Kellie doctrine), blood, CSF, and ultimately brain tissue is forced out of the vault. The normal range of ICP is up to 15 mm Hg; excursions above that level occur normally but readily return to baseline parameters as a result of the adaptive capacity or compensatory mechanisms of the brain and body, such as vasoconstriction and increased venous outflow. In the event of disease, trauma, or a pathological condition, a disturbance in autoregulation occurs, and ICP is increased and sustained. Exceptions include persons with unfused skull fractures (the skull is no longer rigid at the fracture site), infants whose suture lines are not yet fused (this is normal to accommodate growth), and the elderly whose brain tissues have shrunk, taking up less volume in the skull (allowing for abnormal tissue growth or intracranial bleeding to occur for a longer period before symptoms appear).

Related Factors

Defining Characteristics

Expected Outcome

Patient maintains optimal cerebral tissue perfusion, as evidenced by ICP<10 mm Hg, CGS>13, and CPP from 60 mm Hg to 90 mm Hg.

Ongoing Assessment

Actions/Interventions/Rationale

Key:
(i) independent
(c) collaborative

(i) Assess neurologic status as follows: LOC per Glasgow Coma Scale--pupil size, symmetry, and reaction to light; extraocular movement (EOM); gaze preference; speech and thought processes; memory; motor-sensory signs and drift; increased tone; increased reflexes; Babinski reflex.
Deteriorating neurological signs indicate increased cerebral ischemia.
(i) Evaluate presence or absence of protective reflexes (e.g., swallowing, gagging, blinking, coughing, and others).
(i) Monitor vital signs.
Continually increasing ICP results in life-threatening hemodynamic changes; early recognition is essential to survival.
(c) Monitor arterial blood gases (ABGs) and/or pulse oximetry. Recommended parameters of PaO2>80 mm Hg and PaCO2<35 mm Hg with normal ICP. If patient's lungs are being hyperventilated to decrease ICP, PaCO2 should be between 25 and 30 mm Hg.
A PaCO2<20 mm Hg may decrease CBF because of profound vasoconstriction that produces hypoxia. PaCO2>45 mm Hg induces vasodilation with increase in CBF, which may trigger increase in ICP.
(i) Monitor input and output with urine-specific gravity. Report urine-specific gravity >1.025 or urine output <1.50 ml/kg/hr.
May indicate decreased renal perfusion and possible associated decrease in CPP.
(i) Monitor ICP if measurement device is in place. Report ICP>15 mm Hg for 5 minutes.
(i) Calculate cerebral perfusion pressure (CPP).
Calculate CPP by subtracting ICP from the mean systemic arterial pressure (MSAP):
CPP=MSAP-ICP
Determine MSAP using the following formula:
Systolic BP - Diastolic BP + Diastolic BP
               3
Should be approximately 90 mm Hg to 100 mm Hg and not <50 mm Hg to ensure blood flow to brain.
(c) Monitor serum electrolytes, blood urea nitrogen (BUN), creatinine, glucose, osmolality, hemoglobin (HGB), and hematocrit (HCT) as indicated.
To detect treatment complications such as hypovolemia.
(c) Monitor closely when treatment of increased ICP begins to taper.
ICP may increase as treatment is tapered.
(c) Serially monitor ICP pressure and waveforms.
Sustained ICP>15 mm Hg causes transtentorial herniation and brain stem compression/herniation with resultant compression of the respiratory center, apnea, and cardiac arrest. Presence of A and B waves indicates neurological deterioration; the physician should be immediately informed.
Types of ICP waveforms:

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Elevate head of bed 30 degrees, and keep head in neutral alignment.
To prevent decrease in venous outflow with increase in ICP. Exceptions include shock and cervical spine injuries.
(i) Avoid Valsalva's maneuver.
Which increases intrathoracic pressure and CBF, thereby increasing ICP.
(c) If ICP increases and fails to respond to repositioning of head in neutral alignment and head elevation, recheck equipment. If ICP is increased, one or more of the following may be prescribed by the physician:
(i) If ICP is elevated to 12 mm Hg to 15 mm Hg, reduce nursing and medical procedures to those absolutely necessary.
Counteract noxious stimulation with preoxygenation, hyperventilation, and analgesia.
(c) Maintain normothermia with antipyretics, antibiotics and cooling blanket.
Fever increases cerebral metabolic demand; may increase cerebral blood flow and increase intracranial pressure.
(c) Drain CSF at ordered rate and amount.
Removal of a small amount of CSF can significantly lower ICP. This can be accomplished intermittently or, as in patients with hydrocephalus, continuously.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess knowledge of disorder, causes, treatment, and expected outcome.
(i) Define increased ICP (e.g., increased pressure within the skull compressing brain tissues).
(i) Discuss cause if known.
(i) Reinforce discussions related to treatment (e.g., head of bed elevated, medication, intubation, and hyperoxygenation).
(i) Offer family frequent feedback regarding patient's status.
(i) Encourage family presence and participation in comfort measures.
This occasionally calms the patient and decreases ICP.
(i) Provide social service, community, and/or support group information as appropriate to primary diagnosis.
The primary diagnosis (e.g., a resolving head trauma versus repeated stroke) necessitates different levels of postdischarge care needs.

NIC

ICP Monitoring; Neurologic Monitoring; Cerebral Edema Management; Teaching: Disease Process; Medication Administration: Parenteral

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