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NCP Increased intracranial pressure
Nursing (Bsn1)
Adventist University of the Philippines
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Assessment Nursing Diagnosis Planning Nursing interventions /rationale evaluation
Problem: Increased ICP
Subjective:
- Inappropriate words
Objective:
- Vomiting
- 37 C
- 80% O 2 Sat
- GCS 12 (E3V3M6)
- bilaterally reactive pupillary reflex
- agitated behavior
- combative
CT scan results:
- Fx of R parietal & squamous temporal bone
- Extensive subdural hematoma w subarachnoid blood
- midline shift of 10mm
- hemorrhagic contusions on L inf. Temporal lobe
- Raised ICP (>15 mmHg)
Ineffective cerebral tissue perfusion related to increased ICP, hematoma and hemorrhage secondary to Fall from 3rd floor.
Rationale: The client is seen with changes in level of consciousness and a gcs score of 12. The patient also has had a fall from the 3rd flood. Such a fall could very well cause CVI which was later confirmed through CT scan. This increasing ICP can decrease the perfusion of good oxygenated blood to the brain thus causing some of the symptoms of Increased ICP. (Brunner & Suddarth, 2018)
NOC: Neurological Status
Goal: After2 hrs of nursing intervention, pt will display decreased signs of ineffective tissue perfusion as evidenced by gradual improvement of GCS from12 to 14.
After 4 hrs of nursing care, the client will present improved cerebral perfusion as evidenced by an ICP reading of less than 15mmHg and CPP reading of 60-100mmHg
NIC: Cerebral perfusion promotion
-Elevate the head of the bed 15-30 degrees Rationale: In order to reduce blood flow to the
brain with the use of gravity. (Ackley, Ladwig
& Makic, 2017)
-Instruct patients to dangle legs while seated on the side of the bed right after waking up and before standing up. Rationale: reduces the risk of orthostatic hypotension causing worsening of the reduce cerebral perfusion. (Ackley, Ladwig & Makic, 2017)
-assess neuro vital signs frequently Rationale: trauma patients with neurologic damage can often experience life threatening complications very rapidly or subtly if unmonitored. (Ackley, Ladwig & Makic, 2017)
--LOF signs of Cushing’s triad Rationale: to check if there are further complications of increased ICP (Brunner & Suddarth, 2018)
- Administer 50 mg propofol, 150 g fentanyl, and 100 mg recuronium as per doctor’s order Rationale: Meds for CVI, meds reduce fear, and sedate the patient, reducing pain. May increase ICP (Ackley, Ladwig & Makic, 2017)
-Administer Diuretics as per doctor’s order Rationale: they reduce fluid volume in the body thus cause the ICP to stabilize
Goal met, the patients GCS score went up from 12 to 14 after 2hrs of intervention.
Goal not met, the patients ICP reading is still at 16mmHg after 4hrs of nursing intervention
Revise Plan: -continue said interventions, -allot more time for goals -provide oxygenation -enhance environment -encourage family to participate in care
New Evaluation: Goal met, after 8hrs of nursing intervention, patient manifested better cerebral perfusion evidenced by the pts ICP reading was 13 mmHg
Problem 1 (ER SCENE)
Assessment Nursing Diagnosis Planning Nursing interventions w rationale evaluation
NCP Increased intracranial pressure
Course: Nursing (Bsn1)
University: Adventist University of the Philippines
