NCP Increased intracranial pressure PDF

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Summary

A nursing care plan for increased intra cranial pressure...

Description

Assessment

Nursing Diagnosis

Planning

Nursing interventions /rationale

evaluation

Problem: Increased ICP

Ineffective cerebral tissue perfusion related to increased ICP, hematoma and hemorrhage secondary to Fall from 3rd floor.

NOC: Neurological Status

NIC: Cerebral perfusion promotion

Goal met, the patients GCS score went up from 12 to 14 after 2hrs of intervention.

Subjective: -Inappropriate words Objective: - Vomiting - 37.8o C - 80% O2 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)

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)

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

-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) Goal not met, the patients ICP reading is -Instruct patients to dangle legs while seated on still at 16mmHg after the side of the bed right after waking up and 4hrs of nursing before standing up. intervention Rationale: reduces the risk of orthostatic hypotension causing worsening of the reduce Revise Plan: cerebral perfusion. (Ackley, Ladwig & Makic, -continue said 2017) interventions, -allot more time for goals -assess neuro vital signs frequently -provide oxygenation Rationale: trauma patients with neurologic -enhance environment damage can often experience life threatening -encourage family to complications very rapidly or subtly if participate in care 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

Problem 1 (ER SCENE)

New Evaluation: Goal met, after 8hrs of nursing intervention, patient manifested better cerebral perfusion evidenced by the pts ICP reading was 13 mmHg

Assessment

Nursing Diagnosis

Planning

Nursing interventions w rationale

evaluation

Problem: Risk for infection Subjective: None provided Objective: -Post op (surgical incision) for decompressive craniectomy -presence of bolt for ICP monitoring -tracheostomy for suctioning -prolonged stay - Dense left-sided hemiplegia - GCS 11(E4V1M6)

Risk for Infection r/t surgical incision and prolonged presence of ICP monitoring system and tracheostomy. Rationale: an incision opens up the interior of the body to foreign microorganisms that can easily infect the incision wound. Post-surgery factors can also cause the immune system to be particularly weak thus making the body susceptible to acquiring an infection(Brunner & Suddarth, 2018)

NOC: Risk control: Infectious process Goal: After 3 days of nursing intervention, the client will show no signs of infection. This will be evidenced by non-tender surgical incision, dischargeless wound site, tracheostomy and bolt insertion site along with Absence of inflammation. After 2 hrs of health teaching intervention, the patient’s family will identify the 5 signs of inflammation and a return demonstration of care of tracheostomy.

NIC: Infection -Observe for localized signs of infection on all the sites of incision or trauma Rationale: constant monitoring will allow the nurse to detect infection at its primary stage thus allowing for prompt intervention. (Brunner & Suddarth, 2018) -teach the family of the patient the 5 signs of inflammation Rationale: this will allow the caretaker to easily spot the infection in the early stages in case the nurse didn’t notice. (Brunner & Suddarth, 2018)

Goal met, the patient’s family was able to identify 5 signs of inflammation and were able to return -teach the family how to care for a tracheostomy demonstrate the care and the contraindications for this accessory. of a tracheostomy on a Rationale: this will prevent infection and place dummy. the client at less of a risk (Brunner & Suddarth, 2018). -Administer antibiotic prophylaxis as ordered by the doctor Rationale: this will prevent the start of infections and will fight the microorganisms alongside the immunity of the patient (Brunner & Suddarth, 2018). -Practice proper aseptic technique when changing dressing or cleaning incision Rationale: this prevents infections (Brunner & Suddarth, 2018).

Problem 2 (Post OP acene)

Goal met, the patient showed no signs of infection or inflammation at either of the sites of incision or the bolt placement after 3 days of intervention...