Medical Surgical Nursing

 Brain stem herniation

 Diabetes insipidus

 SIADH

Planning and Goals
The goals for the patient include maintenance of a patent airway, normalization of
respiration, adequate cerebral tissue perfusion through reduction in ICP, restoration of
fluid balance, absence of infection, and absence of complications.

Nursing Interventions

Maintaining a Patent Airway
The patency of the airway is assessed. Secretions that are obstructing the airway must
be suctioned with care, because transient elevations of ICP occur with suctioning
(Hickey, 2003). The patient is hyperoxygenated before and after suctioning to maintain
adequate oxygenation. Hypoxia caused by poor oxygenation leads to cerebral ischemia
and edema. Coughing is discouraged, because coughing and straining increase ICP.
The lung fields are auscultated at least every 8 hours to determine the presence of
adventitious sounds or any areas of congestion. Elevating the head of the bed may aid
in clearing secretions and improve venous drainage of the brain.

Achieving an Adequate Breathing Pattern
The patient must be monitored constantly for respiratory irregularities. Increased
pressure on the frontal lobes or deep midline structures may result in Cheyne-Stokes
respirations, whereas pressure in the midbrain can cause hyperventilation. If the lower
portion of the brain stem (the pons and medulla) is involved, respirations become
irregular and eventually cease.
If hyperventilation therapy is deemed appropriate to reduce ICP (by causing cerebral
vasoconstriction and a decrease in cerebral blood volume), the nurse collaborates with
the respiratory therapist in monitoring the PaCO 2 , which is usually maintained at 30 to
35 mm Hg (Hickey, 2003).
A neurologic observation record (Fig. 61-6) is maintained, and all observations are
made in relation to the patient's baseline condition. Repeated assessments of the patient
are made (sometimes minute by minute) so that improvement or deterioration may be
noted immediately. If the patient's condition deteriorates, preparations are made for
surgical intervention.

Optimizing Cerebral Tissue Perfusion
In addition to ongoing nursing assessment, strategies are initiated to reduce factors
contributing to the elevation of ICP (Table 61-2).
Proper positioning helps to reduce ICP. The head is kept in a neutral (midline) position,
maintained with the use of a cervical collar if necessary, to promote venous drainage.
Elevation of the head is maintained at 0 to 60 degrees to aid in venous drainage unless
otherwise prescribed (Fan, 2004). Extreme rotation of the neck and flexion of the neck
are avoided, because compression or distortion of the jugular veins increases ICP.
Extreme hip flexion is also avoided, because this position causes an increase in intra-
abdominal and intrathoracic pressures, which can produce an increase in ICP.
Relatively minor changes in position can significantly affect ICP (Fan, 2004). If
monitoring reveals that turning the patient raises ICP, rotating beds, turning sheets, and
holding the patient's head during turning may minimize the stimuli that increase ICP.