Nursing Care Plan 56-1

Patient with Increased Intracranial Pressure

Nursing Diagnosis*
Decreased Intracranial Adaptive Capacity
Etiology: Decreased cerebral perfusion or sustained increase in ICP
Supporting data: Repeated increases of >10 mm Hg for more than 5 min following a
variety of external stimuli, baseline ICP >20 mm Hg, elevated systolic blood pressure,
bradycardia, widened pulse pressure

Patient Goals
1. Maintains intracranial pressure within normal parameters
2. Ha no serious increases in intracranial pressure during or following care activities

Outcomes (NOC) Interventions (NIC) and Rationales

Neurologic Status
 Cognitive status _____
 Cranial, sensory, and motor
function _____
 Intracranial pressure _____
 Breathing pattern _____
 Pulse pressure _____
 Blood pressure _____
 Radial pulse rate _____
 Communication appropriate
to situation _____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Cerebral Edema Management
 Monitor vital signs to promote cerebral perfusion.
 Monitor neurologic status closely and compare to
baseline to evaluate patient’s response to treatment
and enable immediate reporting and modification of
treatment if necessary.
 Monitor respiratory status: rate, rhythm, depth of
respirations; PaO2, PaCO2, pH, bicarbonate because
low PaO2 and a high hydrogen ion concentration
(acidosis) are potent cerebral blood vasodilators that
increase cerebral blood flow and may increase ICP.
 Analyze ICP waveform to provide an accurate
indicator of ICP.
 Monitor patient’s ICP and neurologic responses to
care activities.
 Position with head of bed up 30 degrees or greater to
promote cerebral venous outflow, reducing ICP.
 Limit suction passes to less than10 seconds to prevent
increased ICP.
 Allow ICP to return to baseline between nursing
activities to prevent sustained increases in ICP.
 Maintain normothermia because elevated temperature
increases cerebral metabolism and causes increased
ICP.
 Give sedation to decrease agitation and hyperactivity
that cause increased ICP.
 Decrease stimuli in patient’s environment to prevent
increases in ICP.

*Nursing diagnoses listed in order of priority.

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eNursing Care Plan 56-2

Outcomes (NOC) Interventions (NIC) and Rationales

Nursing Diagnosis
Risk for Ineffective Tissue Perfusion
Risk factors: decreased cerebral perfusion and cerebral edema

Patient Goal
Maintains cerebral perfusion within normal parameters

Outcomes (NOC) Interventions (NIC) and Rationales

Tissue Perfusion: Cerebral
 Intracranial pressure
_____
 Systolic blood pressure
_____
 Diastolic blood pressure
_____
Measurement Scale
1 = Severe deviation from
normal range
2 = Substantial deviationfrom
normal range
3 = Moderate deviation from
normal range
4 = Mild deviation from
normal range
5 = No deviation from normal
range
 Headache _____
 Restlessness _____
 Impaired cognition _____
 Decreased level of
consciousness _____
 Vomiting _____
 Impaired neurologic
reflexes _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Cerebral Perfusion Promotion
 Consult with HCP to determine hemodynamic
parameters, and maintain hemodynamic parameters
within this range to maintain hemodynamic parameters
and maintain/optimize cerebral perfusion pressure
(CPP).
 Induce hypertension with volume expansion or inotropic
or vasoconstrictive agents, as ordered, to maintain
hemodynamic parameters and maintain/optimize
cerebral perfusion pressure (CPP).
 Consult with HCP to determine optimal head of bed
placement (e.g., 0, 15, or 30 degrees) and monitor
patient’s responses to head positioning to maintain
hemodynamic parameters and maintain/optimize
cerebral perfusion pressure (CPP).
 Monitor determinants of tissue oxygen delivery (e.g.,
PaCO2, SaO2, and hemoglobin levels and cardiac
output), if available, to ensure adequate oxygenation to
support cerebral metabolic needs.
 Calculate and monitor CPP to evaluate adequacy of
cerebral blood perfusion.
 Monitor neurologic status to assess for changes and
prevent complications.
 Monitor intake and output to assess effects of diuretic
and corticosteroid therapy.
Intracranial Pressure (ICP) Monitoring
 Record ICP pressure readings to monitor trends in
cerebral pressure.
 Monitor amount, rate, and characteristics of
cerebrospinal fluid (CSF) drainage to assess for changes
and prevent complications.
 Maintain sterility of monitoring system to prevent
infection.

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eNursing Care Plan
Outcomes (NOC)
Nursing Diagnosis
Risk for Injury
Risk factors: altered level of consciousness, immobility, and altered nutritional intake
Patient Goal
Experiences no complications of immobility
Outcomes (NOC)
Immobility Consequences:
Physiologic
 Lung congestion _____
 Pneumonia _____
 Pressure sore(s) _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
 Nutritional status _____
 Joint movement _____
 Muscle tone _____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Copyright © 2020 by Elsevier, Inc. All rights reserved.
56-3
Interventions (NIC) and Rationales
 Change transducer, flush system, and drainage bag as
indicated to maintain system function and reduce risk of
infection.
 Monitor insertion site for infection or leakage of fluid to
prevent unreliable monitoring results and report
complications to the health care provider.
 Notify HCP about elevated ICP that does not respond to
treatment protocols to initiate early treatment and
prevent complicatons.
Interventions (NIC) and Rationales
Airway Management
 Position patient to maximize ventilation potential to
prevent aspiration and tongue from blocking airway.
 Remove secretions by encouraging coughing or
suctioning to remove accumulated secretions, reduce
risk of aspiration, and ensure patent airway.
 Perform chest physical therapy to mobilize secretions
and prevent pulmonary congestion.
Pressure Ulcer Prevention
 Use an established risk assessment tool to monitor
individual’s risk factors (e.g., Braden scale [see eTable
12-3 on website]).
 Inspect skin over bony prominences and other pressure
points at least daily when repositioning to identify
potential or actual skin problems and initiate a plan of
care.
 Turn every 1-2 hours, as appropriate, because
prolonged pressure decreases circulation and leads to
tissue ischemia and necrosis.
 Turn with care (e.g., avoid shearing forces) to prevent
injury to fragile skin.
 Keep bed linen clean, dry, and wrinkle free to promote
skin integrity.
 Use devices on the bed (e.g., sheepskin) that protect
eNursing Care Plan 56-4

Outcomes (NOC) Interventions (NIC) and Rationales

the patient to absorb moisture and prevent friction.

Nutrition Therapy
 Complete a nutritional assessment to determine
current nutritional status and needs.
 Determine, in collaboration with the dietitian, the
number of calories and type of nutrients needed to
meet nutrition requirements.
 Determine need for enteral tube feedings to meet
nutritional needs if patient is unable to ingest food and
fluids.

Exercise Therapy: Joint Mobility

 Perform passive or assisted ROM exercises to
maintain joint ROM and muscle strength.

ICP, Intracranial pressure; PaCO2, partial pressure of carbon dioxide in arterial blood;
PaO2, partial pressure of oxygen in arterial blood; ROM, range of motion; SaO2, oxygen
saturation of arterial blood.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 56-5

eNursing Care Plan 56-2

Patient with Bacterial Meningitis

Nursing Diagnoses*
Decreased intracranial adaptive capacity†
Risk for ineffective tissue perfusion†

Nursing Diagnosis
Acute confusion
Etiology: impaired cerebral function
Supporting data: inaccurate interpretation of environment, fluctuation in cognition and
level of consciousness, and misperceptions

Patient Goals
1. Demonstrates appropriate cognitive function
2. Is oriented to person, place, and time
Outcomes (NOC) Interventions (NIC) and Rationales
Delirium Level Neurologic Monitoring
 Disorientation of time, place,  Monitor level of consciousness to identify changes.
and person _____  Monitor level of orientation.
 Impaired cognition _____  Monitor vital signs: temperature, blood pressure,
 Difficulty following complex pulse, and respirations because changes in cranial
commands _____ pressure are reflected in vital signs.
 Difficulty interpreting  Note complaint of headache because this is a
environmental stimuli _____ symptom of increased intracranial pressure.
 Misinterpretation of cues  Monitor response to stimuli: verbal, tactile, and
_____ noxious as indicators of cranial pressure.
 Altered level of consciousness  Identify emerging patterns in data to anticipate
_____ changes in treatment.
 Notify HCP of change in patient condition so that
Neurologic Status: changes in therapy may be made as necessary.
Consciousness
 Seizure activity _____ Delirium Management
 Stupor _____  Monitor neurologic status on an ongoing basis to
 Trance state _____ determine extent of problem.
 Delirium _____  Administer PRN medications for anxiety or
 Coma _____ agitation to reduce fear and anxiety.
 Provide a low-stimulation environment for patient
Measurement Scale in whom disorientation is increased by
1 = Severe overstimulation.
2 = Substantial  Approach patient slowly and from the front to avoid

*Nursing diagnoses listed in order of priority.

†Because cerebral edema and increased intracranial pressure may occur with bacterial
meningitis, see the related nursing care plan, NCP 56-1, for these nursing diagnoses.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 56-6

Outcomes (NOC) Interventions (NIC) and Rationales

3 = Moderate stimulating or frightening patient.
4 = Mild  Provide appropriate level of
5 = None supervision/surveillance to monitor patient and to
allow for therapeutic actions.
 Reorient the patient to the health care provider with
each contact to assist with orientation and reduce
anxiety.
 Communicate with simple, direct, descriptive
statements to avoid overstimulation.
 Assist with needs related to nutrition, elimination,
hydration, and personal hygiene because the patient
may lose awareness of the needs.

Nursing Diagnosis
Hyperthermia
Etiology: infection and abnormal temperature regulation by hypothalamus secondary to
increased intracranial pressure
Supporting data: increased body temperature

Patient Goal
Maintains body temperature within normal range
Outcomes (NOC) Interventions (NIC) and Rationales
Thermoregulation Fever Treatment
 Hyperthermia  Monitor temperature and other vital signs to evaluate effects of
_____ hyperthermia.
 Headache _____  Monitor intake and output, being aware of changes in
 Increased skin insensible fluid loss, because increased body temperature
temperature _____ increases the risk of fluid deficit and increases cerebral
 Drowsiness _____ metabolic needs.
 Monitor for fever-related complications and signs and
Measurement Scale symptoms of fever-causing condition (e.g., seizure, decreased
1 = Severe level of consciousness, abnormal electrolyte status, acid-base
2 = Substantial imbalance, cardiac arrhythmia, and abnormal cellular changes)
3 = Moderate because fever increases cerebral metabolism.
4 = Mild  Encourage fluid consumption to replace fluids lost through
5 = None
increased metabolism and diaphoresis.
 Administer medications or IV fluids (e.g., antipyretics,
antibacterial agents, and anti-shivering agents) to reduce fever.

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eNursing Care Plan 56-7

Nursing Diagnosis
Acute pain
Etiology: headache and muscle aches
Supporting data: general discomfort of head, joints, and muscles; apathy; grimacing on
movements

Patient Goals
1. Reports satisfaction with pain control
2. Demonstrates no effects of pain
Outcomes (NOC) Interventions (NIC) and Rationales
Pain Level Pain Management
 Reported pain _____  Perform a comprehensive assessment of pain to include
 Facial expressions of location, characteristics, onset/duration, frequency, quality,
pain _____ intensity, or severity of pain, and precipitating factors to
 Muscle tension _____ plan care for the patient.
 Restlessness _____  Provide patient optimal pain relief with prescribed
analgesics to relieve pain.
Measurement Scale  Select and implement a variety of measures (e.g.,
1 = Severe pharmacologic, nonpharmacologic, interpersonal) to
2 = Substantial facilitate pain relief. Teach the use of nonpharmacologic
3 = Moderate techniques (e.g., relaxation, guided imagery, music therapy,
4 = Mild distraction, hot/cold application, and massage) before,
5 = None
after, and if possible, during painful activities; before pain
occurs or increases; and along with other pain relief
measures.
 Reduce or eliminate factors that precipitate or increase the
pain experience (e.g., fatigue, fear, monotony, and lack of
knowledge).
 Control environmental factors that may influence the
patient’s response to discomfort (e.g., room temperature,
lighting, noise) because pain can be exhausting to the
patient.
 Institute and modify pain control measures based on the
patient’s response.

Collaborative Problem
Potential Complication
Seizure activity related to cerebral irritation
Nursing Goals Nursing Interventions and Rationales
 Monitor for seizure activity  Monitor for seizure activity so that interventions can
 Carry out appropriate medical be initiated immediately.
and nursing interventions  Keep side rails up and padded to protect patient if a
 Report and record any seizure seizure occurs.
activity  Administer sedative and antiseizure medications, as
ordered, to control or prevent seizure activity.

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eNursing Care Plan 56-8

Nursing Goals Nursing Interventions and Rationales

 Perform interventions to treat underlying causes of
inflammatory brain condition to prevent seizure
activity.
ICP, Intracranial pressure; PRN, as needed.

Copyright © 2020 by Elsevier, Inc. All rights reserved.