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  • NCP Increased Icp

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    helloa
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    The patient presented with complaints of dizziness and nausea. An assessment found increased intracranial pressure evidenced by vomiting and altered consciousness. The plan is for 2 hours of nursing interventions to stabilize vital signs and minimize increased ICP signs, followed by 3 days of interventions to improve consciousness. Interventions include elevating the head, dangling legs before standing, monitoring for Cushing's triad, and administering medications to reduce ICP.

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    NCP INCREASED ICP

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    The patient presented with complaints of dizziness and nausea. An assessment found increased intracranial pressure evidenced by vomiting and altered consciousness. The plan is for 2 hours of nursing interventions to stabilize vital signs and minimize increased ICP signs, followed by 3 days of interventions to improve consciousness. Interventions include elevating the head, dangling legs before standing, monitoring for Cushing's triad, and administering medications to reduce ICP.

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    1K views2 pages

    NCP Increased Icp

    Uploaded by

    helloa
    The patient presented with complaints of dizziness and nausea. An assessment found increased intracranial pressure evidenced by vomiting and altered consciousness. The plan is for 2 hours of nursing interventions to stabilize vital signs and minimize increased ICP signs, followed by 3 days of interventions to improve consciousness. Interventions include elevating the head, dangling legs before standing, monitoring for Cushing's triad, and administering medications to reduce ICP.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

    Subjective Ineffective cerebral tissue Short term: Monitor vital signs After 2 hours of nursing
    perfusion related to After 2 hours of nursing interventions, the patient
    “Nahihilo ako at lagging increased intracranial interventions, the patient Rationale: To prevent demonstrated stable vital
    nasusuka” as verbalized pressure as evidenced by will demonstrate stable further complications signs and minimized signs
    by the client. vomiting and altered level vital signs and absence of increased intracranial
    of consciousness. signs of increased Elevate the head of the pressure.
    intracranial pressure. bed 15- 30 degrees.
    Objective: Goal met
    (+) Vomiting Long term: Rationale: To reduce
    (+) Lethargy After 3 days of nursing blood flow to the brain Long term:
    (+) Altered level of interventions, the patient with the use of gravity. After 3 days of nursing
    consciousness. will have improved LOC interventions, the patient
    (+) Fever- 37.7* C Instruct patients to dangle improved his LOC.
    O2 Sat- 90 legs while seated on the
    BP: 150/90 side of the bed after Goal met
    PR: 58 waking up and before
    RR: 17 standing up.

    Rationale: This helps


    reduce the risk of
    orthostatic hypotension
    causing worsening of the
    reduce cerebral perfusion.

    Monitor for signs of


    Cushing’s triad

    Rationale: To check if
    there are further
    complications of
    increased ICP.

    Administer medications
    for management of
    increased ICP and
    administer diuretics as per
    doctor’s order

    Rationale: To reduce fluid


    volume in the body that
    causes the ICP to stabilize.

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