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.