Medical Surgical Nursing

 Achieves healthy oral mucous membranes

 Maintains normal skin integrity

 Has no corneal irritation

 Attains or maintains thermoregulation

 Has no urinary retention

 Has no diarrhea or fecal impaction

 Receives appropriate sensory stimulation

 Family members cope with crisis

o Verbalize fears and concerns

o Participate in patient's care and provide sensory stimulation by talking

and touching

 Patient is free of complications

o Has arterial blood gas values or O 2 saturation levels within normal range

o Displays no signs or symptoms of pneumonia

o Exhibits intact skin over pressure areas

o Does not develop DVT or pulmonary embolism (PE)

Nursing Process

The Patient with Increased Intracranial Pressure

Assessment
Initial assessment of the patient with increased ICP includes obtaining a history of
events leading to the present illness and the pertinent past medical history. It is usually
necessary to obtain this information from family or friends. The neurologic
examination should be as complete as the patient's condition allows. It includes an
evaluation of mental status, LOC, cranial nerve function, cerebellar function (balance
and coordination), reflexes, and motor and sensory function. Because the patient is
critically ill, ongoing assessment is more focused, including pupil checks, assessment
of selected cranial nerves, frequent measurements of vital signs and ICP, and use of the
Glasgow Coma Scale. Assessment of the patient with altered LOC is summarized in
Table 61-1.

Diagnosis
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses for patients with increased
ICP include the following:

 Ineffective airway clearance related to diminished protective reflexes (cough,

gag)

 Ineffective breathing patterns related to neurologic dysfunction (brain stem

compression, structural displacement)

 Ineffective cerebral tissue perfusion related to the effects of increased ICP

 Deficient fluid volume related to fluid restriction

 Risk for infection related to ICP monitoring system (fiberoptic or

intraventricular catheter)

Other relevant nursing diagnoses are included in the section on altered LOC.

Collaborative Problems/Potential Complications
Based on the assessment data, potential complications include: