SCIENTIFIC EXPECTED

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE

EXPLANATION OUTCOME
S>Ø Decreased Intracranial Intracranial pressure, Short term: >Establish rapport >To gain the client and The SO shall have
O> the pt. manifested Adaptive Capacity r/t (ICP), is the pressure SO’s trust. understand the
the ff. Space- Occupying exerted by the cranium After 1-2° of NI the SO >Monitor VS. >To obtain data for client’s condition
Lesion. on the brain tissue, will be able to >Monitor/document comparison. and be able perform
 Altered mental cerebrospinal fluid (CSF), understand the client’s changes in ICP waveform >To alter care actively in
status and the brain's condition and be able and responses to stimuli. appropriately. promoting the
 Speech circulating blood volume. perform actively in >Assess eye opening and clients condition
abnormalities ICP is a dynamic promoting the clients position/movement, > To note degree of having now a higher
 Restlessness phenomenon constantly condition having now a Pupils (size, equality, impairment level of
 Changes in fluctuating in response to higher level of light reactivity), understanding of
mental state activities such as understanding of the purposeful and non- the client’s
AEB (-) pupil exercise, coughing, client’s condition and purposeful motor condition and
reaction to straining, arterial complications that may response comparing left complications that
light, flexion on pulsation, and respiratory occur. and right sides, presence may occur.
pain, no verbal cycle. An increase in of reflexes, nuchal
response. pressure, most commonly Long term: rigidity, consciousness The client shall have
due to head injury and mental state. >To increase SO’s demonstrated
leading to intracranial After 6-7 days of NI the >Provide information understanding of the stable ICP AEB
hematoma or cerebral client will be able to about the client’s client’s condition and normalization of
edema can crush brain demonstrate stable ICP condition including the will be able to decide pressure
tissue, shift brain AEB normalization of complications which may properly for the client’s waveforms/response
structures, contribute to pressure arise once untreated care. to stimuli.
hydrocephalus, cause the waveforms/response to >To promote
brain to herniate, and stimuli. >Elevate HOB and circulation/venous
restrict blood supply to maintain head/neck in drainage
the brain, leading to an midline/neutral position
ischemic cascade. If left >Decrease extraneous >To reduce CNS
untreated the patient stimuli/provide comfort stimulation and
may result to coma or measures promote relaxation.
worst death. >Limit activities that >To decrease factors
increases which may contribute in
intrathoracic/abdominal further increasing ICP.
pressure >To pharmacologically
manage client’s
>Administer medications condition and maintain
as ordered (e.g. homeostasis
antihypertensives,
diuretics, analgesics,
antipyretics,
vasopressors, antiseizure, >To reduce ICP and
neuromuscular blocking enhance circulation
agents, and
corticostreiods) >To have a continuous
>Prepare pt. for surgery client’s care
as indicated (Space
Occupying Lesion)
>Refer accordingly