- Deficient fluid volume related to fluid restriction
- Risk for infection related to ICP monitoring
Collaborative Problems/Potential Complications
- Brainstem herniation
- Diabetes insipidus
- SIADH
- Infection
Nursing Process: The Care of the Patient with Increased Intracranial Pressure—
Planning
- Major goals may include:
- Maintaining a Patent Airway
- Achieving an Adequate Breathing Pattern
- Preventing Infection
- Optimizing Cerebral Tissue Perfusion
- Maintaining Negative Fluid Balance
- Absence of complications
Interventions
- Frequent monitoring of respiratory status and lung sounds and measures to maintain a
patent airway (suction is contraindicated)
- Position with head in neutral position and elevation of HOB 0–60° to promote venous
drainage - Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may
increase ICP
- Maintain a calm, quiet atmosphere and protect patient from stress
- Monitor fluid status carefully; every hour I&O during acute phase
- Use strict aseptic technique for management of ICP monitoring system