Nursing diagnosis:Ineffective tissue perfusion related to increased intracranial

pressure
Goal:Patient is alerted and oriented: motor, cognitive, and sensory function are
within acceptable parameters
• Monitor vital signs and neurological status.
• Observe for any signs of increased intracranial pressure.
• Assess for nuchal rigidity, twitching, increased restlessness, and irritability.
• Monitor arterial blood gases (ABGs) and oxygen saturation.
• Maintain head or neck in midline position
• During reposition, avoid bending of the knee and pushing heels against the
mattress.
• Elevate the head of the bed 30°, and avoid neck flexion and hip flexion
• Administer oxygen as needed
• Osmotic diuretic: Mannitol (Osmitrol
• Anticonvulsants: Diazepam (Valium) or phenytoin (Dilantin)
• Provide comfort measures and decrease external stimuli such as dim
light environment, soft voice, and gentle touch.