Nurse Care Plan

Intracranial pressure is the force exerted in the cranium by your intracranial components.
INTRACRANIAL COMPONENTS
a. Brain-80%
b.Blood-10%
c.Cerebrospinal Fluid (CSF)-10%
Normal Flactuations of ICP
a. Bending forward
b. Straining
c. Coughing, Sneezing
d. Prolonged immobility
Risk Factors
a. Head Injury
b. Hemorrhage
c. Cerebral Edema
d. Hydrocephalus
Cause
Unknown
Compensatory Mechanism
a. displacement of the CSF from the ventricles tothe subarachnoid
b. reduction of cerebral blood flow
c. displacement of brain tissue towards the spinal canal
Diagnostic Test
a. CT Scan
b.Magnetic Resonance Imaging (MRI)
Clinical Manifestation
a. Altered level of consciousness (LOC)
b. Nausea and vomiting- due to compression of the Medulla Oblongata
c. Headache
d. Speech problem
e. Pupillary reaction
f. Seizure
g. Fever
h. Cushing's Triad-Increase BP, decrease PR & RR
Nursing Management
Pharmacologic
a. Antipyretic-treatment for fever
-fever increases cerebral metabolic demand which increases ICP
b. Osmotic Diuretic-mannitol
- to dehydrate the brain
c. Anticonvulsant- phenytoin (Dilantin) Drug of Choice
- to manage seizure
- watch for Gingival hyperplasia (bleeding)
d. Stool Softeners- to avoid straining
e. Corticosteroids- anti-inflammatory like dexamethasone
Nursing Management
a. Ellevate the patients head 15-30 degrees to promote venous return
b. Avoid extreme flexion of neck(to avoid jugular veins compression), hips ( to avoid abdominal compression)
c. Limit the environmental stimuli
d. Side rails up
e. Avoid straining like valsalva maneuver
-increasefiber intake
f. Suctioning