Medical Surgical Nursing

o Assess patient's level of responsiveness/consciousness; decreased level
of consciousness may be the first sign of increased ICP.
 Eye opening (spontaneous, to sound, to pain); pupillary reactions
to light
 Response to commands
 Assessment of spinal motor reflexes (pinch Achilles tendon, arm,
or other body site)
 Observation of patient's spontaneous activity
o Maintain a neurologic flow sheet to assess and document neurologic
status, fluid administration, laboratory data, medications, and treatments.
o Evaluate for signs and symptoms of increasing ICP, which can lead to
ischemia and further impairment of brain function.
 Assess patient minute by minute, hour by hour, for
 Diminished response to stimuli
 Fluctuations of vital signs
 Restlessness
 Weakness and paralysis of extremities
 Increasing headache
 Changes or disturbances of vision; pupillary changes
 Modify nursing management to prevent further increases in ICP.
o Control postoperative cerebral edema as prescribed.
 Administer corticosteroids and osmotic diuretics as prescribed to
reduce brain swelling.
 Monitor fluid intake; avoid overhydration.
 Maintain a normal temperature. Temperature control may be
impaired in certain neurologic states, and fever increases the
metabolic demands of the brain.
 Monitor rectal temperature at specified intervals. Assess
temperature of extremities, which may be cold and dry
due to impaired heat-losing mechanisms (vasodilation
and sweating).
 Employ measures as prescribed to reduce fever: ice bags
to axillae and groin; hypothermia blanket. Use ECG
monitoring to detect dysrhythmias during hypothermia
procedures.
 Employ hyperventilation when prescribed and indicated (results
in respiratory alkalosis, which causes cerebral vasoconstriction
and reduces intracranial pressure).
 Elevate head of bed to reduce ICP and facilitate respirations.
 Avoid excessive stimuli.
 Use ICP monitoring if patient is at risk for intracranial
hypertension.
 Intracranial hemorrhage
o Postoperative bleeding may be intraventricular, intracerebellar, subdural,
or extradural.
o Observe for progressive impairment of state of consciousness and other
signs of increasing ICP.
o Prepare deteriorating patient for return to surgery for evacuation of
hematoma.
 Seizures (greater risk with supratentorial operations)