E-NURSING NCM431

INTRACRANIAL
PRESSURE
MONITORING
TRAUMATIC SPINAL CORD INJURY
GROUP 9 ENTER
E-NURSING 4 Basic ICP
Contents Definition Monitoring System Indications Video of the Nursing Nursing Diagnosis
NCM 431 Procedure Responsibilities NCP

What You Will Learn

4 Basic ICP
DEFINITION Monitoring
system

VIDEO OF
INDICATIONS
Contents THE
PROCEDURE

NURSING
RESPONSIBILITIES NURSING
DIAGNOSIS

NCP
(TRAUMATIC
SPINAL CORD REFERENCES
INJURY)
E-NURSING 4 Basic ICP Video of the Nursing Nursing Diagnosis
Contents Definition Monitoring System Indications NCP
NCM 431 Procedure Responsibilities

The purpose of ICP monitoring is to detect early

elevation of ICP before any clinical danger signs
develop. Given that small changes in a healthy

WHAT IS ICP brain’s ICP related to coughing, sneezing, and

straining are well tolerated, changes in a brain-

MONITORING? injured individual can be fatal. So prompt

Intracranial pressure (ICP) monitoring measures pressure
exerted by the brain, blood, and cerebrospinal fluid (CSF)
against the inside of the skull. The normal intracranial
pressure in adults ranges from 0-15 mmHg, but ICP can also
depart from a “normal range” based on other factors such
as age, body posture, and other clinical conditions.
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intervention is vital to help avert or diminish further
neurologic damage.
There are four basic ICP monitoring systems:
intraventricular catheter, subarachnoid bolt, epidural
sensor, and intraparenchymal pressure monitoring.
Regardless of which system is used, the procedure is
always performed by a neurosurgeon in the operating
room, emergency department, or intensive care unit
(ICU).
Intracranial pressure (ICP) monitoring measures pressure
exerted by the brain, blood, and cerebrospinal fluid (CSF)
against the inside of the skull. The normal intracranial
pressure in adults ranges from 0-15 mmHg, but ICP can also
depart from a “normal range” based on other factors such
as age, body posture, and other clinical conditions.
E-NURSING 4 Basic ICP
Video of the Nursing Nursing Diagnosis
Contents Definition Monitoring System Indications NCP
NCM 431 Procedure Responsibilities

INTRAVENTRICULAR SUBARACHNOID BOLT

CATHETER

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E-NURSING 4 Basic ICP
Video of the Nursing Nursing Diagnosis
Contents Definition Monitoring System Indications NCP
NCM 431 Procedure Responsibilities

INTRAPARENCHYMAL
EPIDURAL SENSOR PRESSURE MONITORING

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E-NURSING 4 Basic ICP Video of the Nursing Nursing Diagnosis
Contents DefinitionMonitoring System Indications NCP
NCM 431 Procedure Responsibilities

INDICATIONS

INTRACRANIAL HEMORRHAGE OVERPRODUCTION OR

INSUFFICIENT ABSORPTION OF CSF
(HYDROCEPHALUS)

CEREBRAL EDEMA
SPACE - OCCUPYING BRAIN LESIONS
SUCH AS SUBDURAL AND EPIDURAL
SEVERE TRAUMATIC BRAIN INJURY

OCCLUSION OF THE CSF PATHWAY

CAUSED BY HEMATOMAS,
POST-CRANIOTOMY ABSCESSES, TUMORS, OR
ANEURYSMS

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E-NURSING 4 Basic ICP Video of the Nursing Nursing Diagnosis
Contents DefinitionMonitoring System Indications NCP
NCM 431 Procedure Responsibilities

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E-NURSING 4 Basic ICP Video of the Nursing Nursing Diagnosis
Contents DefinitionMonitoring System Indications NCP
NCM 431 Procedure Responsibilities

BEFORE
Obtain baseline routine and neurologic vital signs to aid in prompt detection of decompensation during the procedure.

Determine whether the patient is allergic to iodine preparations.

Explain the procedure to the patient or his family.

Make sure the patient or a responsible family member has signed a consent form.

Provide privacy if the procedure is being done in an open emergency department or ICU.

Conduct a pre-procedure verification process to make sure that all relevant documentation, related information, and equipment are available and correctly identified
to the patient identifiers.

Verify that the laboratory and imaging studies have been completed as ordered and that the results are in the patient’s medical record. Notify the doctor of any
unexpected results.

Perform handwashing and put on gloves. Wear appropriate personal protective equipment.

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E-NURSING 4 Basic ICP Video of the Nursing Nursing Diagnosis
Contents DefinitionMonitoring System Indications NCP
NCM 431 Procedure Responsibilities

DURING
Place the patient in the supine position, and elevate the head of the bed 30 degrees (or as ordered).

Place linen-saver pads under the patient’s head.

Shave or clip his hair at the insertion site, as indicated by the physician, to decrease the risk of infection. Carefully fold and remove the linen-saver pads to avoid
spilling loose hair onto the bed.

To facilitate placement of the device, hold the patient’s head in your hands or attach a long strip of 4 roller gauze to one side rail, and bring it across the patient’s
forehead to the opposite rail.

Reassure the conscious patient or administer reversible, quick-acting sedation to help ease his anxiety. Talk to him frequently to assess his level of consciousness
(LOC) and detect signs of deterioration.

Watch for cardiac arrhythmias and abnormal respiratory patterns.

After insertion, apply povidone-iodine solution and a sterile dressing to the site.

Inspect the insertion site at least every 4 hours (or according to your facility’s policy) for redness, swelling, and drainage.

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E-NURSING 4 Basic ICP Video of the Nursing Nursing Diagnosis
Contents DefinitionMonitoring System Indications NCP
NCM 431 Procedure Responsibilities

AFTER
Record the time and date of the insertion procedure, dressing appearance, and the patient’s response.

Note the insertion site and the type of monitoring system used. Change the dressing according to your facility’s policy.

Record ICP digital readings and waveforms and CPP hourly in your notes, on a flowchart, or directly on readout strips, depending on your facility’s policy.

Document any factors that may affect ICP (for example, drug administration, stressful procedures, or sleep). Record routine and neurologic vital signs hourly —
or more frequently if the patient’s condition warrants — and describe the patient’s clinical status.

Note the amount, character, and frequency of any CSF drainage.

Record the ICP reading in response to drainage.

To reduce the risk of infection, change the dressing at the insertion site daily using sterile technique.

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E-NURSING 4 Basic ICP Video of the Nursing Nursing Diagnosis
Contents Definition Monitoring System Indications NCP
NCM 431 Procedure Responsibilities

PRIORITY NURSING DIAGNOSIS ENTER

1 2 3 4 5

RISK FOR
IMPAIRED DISTURBED
INEFFECTIVE RISK FOR ACUTE
PHYSICAL SENSORY
BREATHING TRAUMA PAIN
MOBILITY PERCEPTION
PATTERN

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E-NURSING 4 Basic ICP Video of the Nursing Nursing DiagnosisNCP
Contents DefinitionMonitoring System Indications
NCM 431 Procedure Responsibilities

NURSING CARE PLAN FOR TRAUMATIC SPINAL CORD INJURY ENTER

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 ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL
Risk for Ineffective Breathing Pattern as Evidenced
SUBJECTIVE CUES: by Spinal Cord Injury (C6)  Short-Term:
“Pagka-bangga nako sa usa pa ka- SCIENTIFIC BASIS:
motor kay nalagpot ko then ang luyo When a person has a spinal cord injury, signals sent After nursing management, patient will
jud nako ang nag-una. Karon kay from the brain can no longer pass beyond the establish and maintain adequate
medyo maglisod kog ubo ug ginhawag damage to the spinal cord, so the brain can no longer
lawm.”, as verbalized by the patient. ventilation.
control the muscles that one would normally use for
inhaling and exhaling, namely the diaphragm,
intercostal and abdominal muscles. The extent of the
OBJECTIVE muscle control loss depends on the level of injury
CUES: and if there is complete or incomplete spinal cord
damage.
• X-ray result shows injury on C6 C1 to C3 injuries result in complete loss of
• Weak cough observed respiratory function. Injuries at C4 or C5 can result
• Profuse sweating and restlessness noted in variable loss of respiratory function, depending on
• ABG lab results: phrenic nerve involvement and diaphragmatic
• pH = 7.36 function, but generally cause decreased vital Long-Term:
• PCO2 = 39 mmHg capacity and inspiratory effort. For injuries below
• PHCO3 = 24 mEq/L C6 or C7, respiratory muscle function is preserved; After nursing management, patient will
• PO2 = 78 mmHg  however, weakness and impairment of intercostal
demonstrate appropriate behaviors to
• With the following vital signs: muscles may reduce effectiveness of cough, ability
to sigh, and take deep breaths. support respiratory effort.
• T = 37.6°C
• P = 67 bpm
REFERENCE/S:
• R = 21 cpm 
• BP = 100/70 mmHg Respiratory Health and Spinal Cord Injury. (2015). Model
Systems Knowledge Translation Center (MSKTC).
• SPO2 = 90%
https://msktc.org/sci/factsheets/respiratory
 OUTCOME CRITERIA
Short-Term:
Specifically, within 48 hours of nursing
interventions, the client will:
• have normal breathing rate and pattern
(RR=12 – 20 cpm) and improved SPO2
(90% or greater)
• have ABGs within acceptable limits: pH =
7.35 – 7.45; PCO2 = 35 – 45 mmHg;
PHCO3 = 22 – 26 mEq/L; PO2 = 80 – 100
mmHg
• be free from pulmonary infections.
• have normal skin color and free from
cyanosis.
Long-Term:
Specifically, within 7 days of nursing
interventions, the client will be able to:
• demonstrate effective coughing
technique.
• participate in deep breathing exercise
three to four times a day.
• maintain adequate fluid intake of at least
1.5 – 2 L/day.
• initiate repositioning every two hours.
NURSING RATIONALE
INTERVENTIONS
Independent: 1. For injuries below C6 or C7,
1. Noted presence or absence of spontaneous respiratory muscle function is preserved;
effort and quality of respirations— labored, however, weakness and impairment of
using accessory muscles. intercostal muscles may reduce
effectiveness of cough, ability to sigh, and
2.Auscultated breath sounds. Noted areas of take deep breaths.
absent or decreased breath sounds or
development of adventitious sounds, such as 2. Hypoventilation is common and leads
rhonchi. to accumulation of secretions, atelectasis,
and pneumonia— frequent complications.
Note: Respiratory complications are
among the leading causes of mortality, not
3.Assisted with coughing, as indicated for level only during the acute stage but also later in
of injury; for example, had the client take a deep life.
breath, hold for 2 seconds before coughing, or 3.
Assisted coughing facilitates
inhale deeply, then cough at the end of a slow mobilization of respiratory secretions.
exhalation. Alternatively, assisted by placing Note: Quad cough procedure is generally
hands below diaphragm and pushing upward as reserved for clients with stable injuries
client exhales (“quad cough”). once they are in the rehabilitation stage.
4.Maintained open airway: Kept head in neutral
position, elevated head of bed slightly if 4. Client with high cervical injury and
tolerated, and used airway adjuncts, as indicated. impaired gag or cough reflex requires
assistance in preventing aspiration and
maintaining patent airway.
5.Suctioned only as necessary. Monitored pulse
oximetry and heart rate during suctioning. 5. Suctioning facilitates removal of
Documented quality and quantity of secretions. respiratory secretions. However, routine or
lengthy suctioning increases the risk for
bradycardia and hypoxia, especially with
tetraplegia.
 NURSING
INTERVENTIONS
6.Provided fluids—at least 1500 to 2000
mL/day, within cardiac tolerance.
7.Repositioned and turned periodically.
Avoided or limited prone position, as
appropriate.
8. Assessed for abdominal distention and
muscle spasm.
9. Assisted client in “taking control” of
respirations as indicated. Encouraged
deep breathing. Instructed to focus
attention on the steps of breathing.
10. Monitored for signs of infection (e.g.,
fever, changes in breath sounds,
increased cough with purulent sputum).
RATIONALE
6. Promotes mobilization of secretions.
7. Repositioning enhances ventilation of all
lung segments and mobilizes secretions. It
helps reduce the risks of complications such as
atelectasis and pneumonia. Note: Prone
position significantly decreases vital capacity
and increases risk of respiratory compromise
and failure.
8. Abdominal fullness may impede
diaphragmatic excursion, thus reducing lung
expansion and further compromising
respiratory function.
9. Depending on level of injury or involvement
of respiratory muscles (muscle fatigue),
breathing may no longer be an involuntary
activity but require conscious effort.
10. Pneumonia is a frequent early complication
possibly because of aspiration and high- dose
steroids used in early treatment of the SCI.
 NURSING
INTERVENTIONS RATIONALE

11. Monitored for respiratory muscle 11. Developing respiratory distress

fatigue. Observed skin color for developing accompanied with changes in skin color may
cyanosis or duskiness. reveal impending respiratory failure and need
for immediate medical evaluation and
intervention/ mechanical ventilation.

12. Development of pulmonary emboli may

12. Investigated sudden onset of dyspnea, be “silent” because pain perception is altered
cyanosis, and other signs of respiratory and deep vein thrombosis (DVT) is not
distress. readily recognized.

13. Vital signs are monitored to show well

the body is functioning. In patient’s case, it
13. Monitored vital signs and pulse
may provide insight on patient’s respiratory
oximetry.
function. The pulse oximeter observes a rapid
measurement of oxygen saturation level in
your body without using needles or taking a
blood sample.
 NURSING
INTERVENTIONS
Dependent:
14. As per doctor’s order, administered
oxygen by appropriate method: nasal
prongs, mask, intubation, and ventilator.
Collaborative:
15. Measured and graphed:
• vital capacity (VC), total lung
volumes (VT), and inspiratory force.
• serial ABGs.
RATIONALE
14. Oxygen delivery methods are determined
by level of injury, degree of respiratory
insufficiency, and respiratory muscle function
after spinal shock phase.
15.
• Determines level of respiratory muscle
function. Serial measurements may predict
impending respiratory failure (acute injury)
or determine level of function after spinal
shock phase or while weaning from
ventilatory support.
• Documents status of ventilation and
oxygenation and identifies respiratory
problems, such as hypoventilation,
hypoxia, and acidosis, among others.
 NURSING ACTUAL
INTERVENTIONS RATIONALE
EVALUATION
16. Assisted with use of respiratory 16. Preventing retained secretions is essential Short Term:
adjuncts, such as incentive spirometer or to maximize gas diffusion and to reduce risk After nursing management, patient
blow bottles, and aggressive chest of pneumonia. established and maintained adequate
physiotherapy, such as chest percussion. ventilation.

17. Referred to or consulted with Specifically, within 48 hours of nursing

respiratory and physical therapists.
17. Collaboration with respiratory and
physical therapists helps identify appropriate
therapies that could optimize respiratory
function. For example, glossopharyngeal
breathing uses muscles of mouth, pharynx,
and larynx to swallow air into lungs, thereby
increasing vital capacity and chest expansion.
REFERENCE:
Doenges, M. E., Moorhouse, M. F., & Murr,
A. C. (2019). Nursing Care Plans: Guidelines
for Individualizing Client Care Across the
Life Span (10th ed.). F.A. Davis.
interventions, the patient:
• had normal breathing rate and
pattern (RR = 18 cpm) and improved
SPO2 (SPO2= 95%)
• had normal ABG results:
• pH = 7.38
• PCO2 = 40 mmHg
• PHCO3 = 24 mEq/L
• PO2 = 88 mmHg
• remained free from pneumonia and
other pulmonary infections.
• had normal skin color and was free
from cyanosis.
 NURSING ACTUAL
INTERVENTIONS RATIONALE
EVALUATION
Long Term:

After nursing management, patient

demonstrated appropriate behaviors to
support respiratory effort.

Specifically, within 7 days of nursing

interventions, the patient:

• demonstrated effective coughing

technique.
• participated in deep breathing
exercise three times a day.
• maintained adequate fluid intake of
1.5L/day.
• asked for assistance in
repositioning every two hours.

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E-NURSING 4 Basic ICP
Video of the Nursing Nursing Diagnosis
Definition Monitoring System Indications NCP References
NCM 431 Procedure Responsibilities

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing Care Plans:
Guidelines for Individualizing Client Care Across the Life Span (10th ed.). F.A.
Davis.
Nurse Key. (2016, July 21). Intracranial Pressure Monitoring. Retrieved from Nurse
Key: Fastest nurse insight engine: https://nursekey.com/intracranial-pressure-
monitoring/

Respiratory Health and Spinal Cord Injury. (2015). Model Systems Knowledge

Translation Center (MSKTC). https://msktc.org/sci/factsheets/respiratory​

Salmon, N., Polinsky, S., & Muck, K. (2015). Increased Intracranial Pressure
and Monitoring. AMN Healthcare Education Services, 17. SAVE
Vera, M. (2019, April 11). 12 Spinal Cord Injury Nursing Care Plans.
Retrieved from nurseslabs: https://nurseslabs.com/12-spinal-cord-
injury-nursing-care-plans/
CANCEL

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GROUP 9

RIVERA, B.

ARNADO, E. RETUYA, A. LAÑAS, F. JULIO, L. VICTORIOSO, R.

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