Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 17-6

Caring for a Patient With a Fiber

Optic Intracranial Catheter

Goal:The patient maintains ICP less than 10 to 15 mm Hg,

and CPP 60 to 90 mm Hg. Comments

1. Review the medical orders for specific information about
   monitoring parameters.


2. Gather the necessary supplies and bring to the bedside
   stand or overbed table.


3. Perform hand hygiene and put on PPE, if indicated.


4. Identify the patient.


5. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do and why you
   are going to do it to the patient.


6. Assess patient for any changes in neurologic status. (See
   Chapter 2, Health Assessment, for details of assessment.)


7. Assess ICP, MAP, and CPP at least hourly. Note ICP wave-
   forms as shown on the monitor.Notify the primary care
   provider if A or B waves are present.


8. Care for the insertion site according to the institution’s
   policy. Assess the site for any signs of infection, such as
   drainage, redness, or warmth. Ensure the catheter is
   secured at site per facility policy.


9. Calculate the CPP, if necessary. Calculate the difference
   between the systemic MAP and the ICP.


10. Remove PPE, if used. Perform hand hygiene.

ExcellentSatisfactoryNeeds Practice