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    Nursing Care Plan

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    Jayalakshmi David
    The nursing care plan is for a patient with increased intracranial pressure following a brain injury. Goals include returning the patient home while caring for themselves with family support. Key nursing diagnoses address maintaining normal intracranial pressure and cerebral perfusion pressure. Interventions include frequent monitoring of vitals, ICP, blood gases and pressure to manage the patient's condition through protocols and physician notification. Positioning, temperature control and limiting activities are aimed to reduce ICP. Blood pressure management seeks to support adequate cerebral perfusion. Risk of aspiration is addressed through positioning, airway management and mouth care.

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    Nursing Care Plan

    Uploaded by

    Jayalakshmi David
    4K views3 pages
    The nursing care plan is for a patient with increased intracranial pressure following a brain injury. Goals include returning the patient home while caring for themselves with family support. Key nursing diagnoses address maintaining normal intracranial pressure and cerebral perfusion pressure. Interventions include frequent monitoring of vitals, ICP, blood gases and pressure to manage the patient's condition through protocols and physician notification. Positioning, temperature control and limiting activities are aimed to reduce ICP. Blood pressure management seeks to support adequate cerebral perfusion. Risk of aspiration is addressed through positioning, airway management and mouth care.

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    The nursing care plan is for a patient with increased intracranial pressure following a brain injury. Goals include returning the patient home while caring for themselves with family support. Key nursing diagnoses address maintaining normal intracranial pressure and cerebral perfusion pressure. Interventions include frequent monitoring of vitals, ICP, blood gases and pressure to manage the patient's condition through protocols and physician notification. Positioning, temperature control and limiting activities are aimed to reduce ICP. Blood pressure management seeks to support adequate cerebral perfusion. Risk of aspiration is addressed through positioning, airway management and mouth care.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    4K views3 pages

    Nursing Care Plan

    Uploaded by

    Jayalakshmi David
    The nursing care plan is for a patient with increased intracranial pressure following a brain injury. Goals include returning the patient home while caring for themselves with family support. Key nursing diagnoses address maintaining normal intracranial pressure and cerebral perfusion pressure. Interventions include frequent monitoring of vitals, ICP, blood gases and pressure to manage the patient's condition through protocols and physician notification. Positioning, temperature control and limiting activities are aimed to reduce ICP. Blood pressure management seeks to support adequate cerebral perfusion. Risk of aspiration is addressed through positioning, airway management and mouth care.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Nursing Care Plan

    Nursing Care Plan Client with increased intracranial pressure.


    Long term goals: Patient will return home able to care for himself with the support of his family.
    Nursing Diagnosis:  Decreased Intracranial Adaptive Capacity related to brain injury

    Outcome/Short Term Planning/Interventions Rationale for Evaluation


    Patient Centered Goals Implementation interventions
    Patient will have   Monitor patient’s It is imperative to ICP will remain less
    intracranial  pressure neurologic status, ICP identify when the than 20 (preferably
    within normal range. and vital signs at least patient’s ICP is less than 15).
    every hour. increasing and to
        Notify physician for institute collaborative Glasgow Coma Scale
    collaborative measures to decrease will be 13 or higher.
      management or institute it.  Intracranial
    a protocol to respond to pressure increases may  
      a sustained ICP greater also be limited by
    than 20. enhancing venous
         Maintain patient’s drainage from the
    head of the bed at 30 head, maintaining the
    degrees elevation or patient in a
    higher and patient’s normothermic state,
    body in a neutral preventing episodes of
    position. Do not allow hypercarbia,
    pronounced neck or hip hypocarbia and
    flexion. hypoxia as well as
      Monitor the patient’s allowing the patient a
    temperature and chance to rest and the
    maintain it within ICP to return to
    designated parameters, baseline between
    aggressively treat activities. 
    hyperthermia.
       Monitor patient’s
    blood gases, collaborate
    with physician and
    respiratory therapist to
    resolve hypercarbia,
    hypocarbia, or
    hypoxia. 
      Suction only after
    preoxygenating the
    patient and for less than
    10 seconds at a time.
       Spread nursing
    activities out, do not
    cluster them

    Nursing Diagnosis: Ineffective Tissue Perfusion related to increased intracranial pressure and
    decreased cerebral perfusion pressure 

    Planning/Interventions Rationale for Evaluation


    Outcome/Short Term Implementation interventions
    Patient  Centered
    Goals
       Monitor the patient’s Maintenance of a CPP= 60
    blood pressure.  Notify systolic pressure of at
    Patient will have a the physician or least 90 is only one of
    cerebral perfusion institute a management several factors
    pressure (CPP) of at protocol should the necessary to maintain
    least 50 preferably 60.  systolic BP fall below adequate perfusion of
    90 mm Hg. the brain.  A CPP less
        Notify the physician than 50 should be
    for a BP greater than avoided since it is
      180 systolic. associated with loss of
      Calculate the mean autoregulation of the
      arterial pressure (MAP) brain and poor patient
    and the CPP. outcomes. 
    When CPP is decreased
    institute either methods
    to decrease ICP (see
    above) or increase
    MAP.
      Collaborative
    measures to increase
    MAP may include NS  
    or RL infusion or
    possibly hypertonic
    saline. 

    Nursing Diagnosis : Risk for Aspiration related to reduced level of consciousness and depressed
    cough and gag reflexes

    Planning/Interventions Rationale for Evaluation


    Outcome/Short Term Implementation interventions
    Patient Centered Goals
       Maintain head of bed   Positioning the Chest x-ray, lung
    elevated higher than 30 patient with the head sounds and arterial
    degrees. of the bed elevated has blood gases  normal or
    Client will not aspirate.  If patient is intubated, been shown to be an at patient’s baseline.
    maintain ETT cuff effective part of the
      pressure at 25 mmHg, if ventilator bundle at  
    possible suggest the use reducing aspiration
      of an ETT with and pneumonia. 
    continuous subglottic   The use of a CASS
      suctioning (CASS) tube and provision of
    tube. mouth care may
      Provide mouth care decrease the incidence
    per policy. of aspiration of
       Assure proper bacteria.
    placement of a feeding
    tube and assess  Proper placement of
    gastrointestinal the tube and assurance
    functioning prior to and that there are not
    during feeding. excessive residuals
      limits the possibility of
    aspiration.

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