NAME: CRYSTAL JADE S.

RESURRECCION
YEAR/SECTION: BSN 4Y2-2
WEEK 2 COURSE TASK FOR INCREASED ICP

1. Make 2 priority NCP (ADPIE) for client with clinical manifestations of Increased Intracranial Pressure

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE Ineffective cerebral Goal: 1. Establish 1. To gain patient’s Goal met, the
DATA: tissue After 2 hrs of nursing rapport. trust. patients GCS
perfusion related to intervention, patient 2. Assess vital 2. To obtain baseline
Inappropriate words score went up
increased ICP, will signs. data.
hematoma display decreased 3. Instruct 3. To reduces the risk from 12 to 14
and hemorrhage signs patients to of orthostatic after 2hrs of
OBJECTIVE
secondary to Fall of ineffective tissue dangle legs hypotension
intervention.
DATA: from 2ND perfusion as while seated causing worsening
floor. evidenced on the side of of the reduce Goal not met,
Vital signs:
by gradual the bed right cerebral perfusion. the patients ICP
TEMP: 37.8
improvement after waking 4. to check if there are
reading is still at
HR: 98 of GCS from12 to 14. up and further
After 4 hrs of nursing before complications of 16mmHg after
RR: 12
care, the client will standing up. increased ICP. 4hrs of nursing
O2 SAT: 80%
present improved 4. Look out for 5. Pupil reactions are intervention
- Vomiting cerebral perfusion as signs of regulated by the
evidenced by an ICP cushing’s oculomotor cranial Revise Plan:
- GCS 12 (E3V3M6)
reading of less than triads. nerve and are useful continue said
- bilaterally reactive
15mmHg and CPP 5. Evaluate in determining interventions,
pupillary reflex reading of 60- pupils, noting whether the
-allot more time
- agitated behavior 100mmHg size, shape, brainstem is intact.
equality, and 6. Valsalva’s for goals
- combative
light and maneuver increases -provide
reactivity. ICP and potentiates
oxygenation
risk of bleeding.
NAME: CRYSTAL JADE S. RESURRECCION
YEAR/SECTION: BSN 4Y2-2
6. Prevent 7. Continual -enhance
straining at stimulation can environment
stool or increase icp more.
-encourage
holding Absolute rest and
breath. quiet environment family to
7. Maintain must need. participate in
bedrest, Collaborative:
care
provide 8. Meds for CVI,
quiet, and meds reduce fear, New Evaluation:
restrict and sedate the Goal met, after
visitors or patient, reducing
8hrs of nursing
activities, as pain. May increase
indicated. ICP. intervention,
Collaborative: 9. They reduce fluid patient
8. Administer volume in the body manifested
50 mg thus cause the ICP
propofol, to stabilize. better cerebral
150g perfusion
fentanyl, and evidenced by the
100 mg
pts ICP reading
recuronium
as per was 13 mmHg.
doctor’s
order.
9. Administer
Diuretics as
per doctor’s
order.
NAME: CRYSTAL JADE S. RESURRECCION
YEAR/SECTION: BSN 4Y2-2
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE Risk for Infection r/t Goal: After 3 days of 1. Establish 1. To gain patient’s Goal met, the
DATA: surgical incision and nursing intervention, rapport. trust. patient showed
None provided. prolonged presence of the client will show 2. Assess vital 2. To obtain no signs of
ICP monitoring system no signs of infection. signs. baseline data. infection or
OBJECTIVE and tracheostomy. This will be 3. Monitor 3. Signs of inflammation at
DATA: evidenced by non- effectiveness of improvement in either of the
-Post op (surgical tender surgical antimicrobial condition should sites of incision
incision) incision, therapy. occur within 24 or the bolt
for decompressive discharge less wound 4. Limit visitors as to 48 hours. placement
craniectomy site, tracheostomy indicated. 4. Reduces after 3 days of
-presence of bolt and bolt insertion site 5. Change position likelihood of intervention
for ICP along with Absence frequently and exposure to the Goal met, the
monitoring of provide and other infectious patient’s
-tracheostomy for inflammation. provide good pathogens. family was able
suctioning After 2 hrs of health pulmonary toilet. 5. Promotes to identify 5
-prolonged stay teaching 6. Observe for expectoration, signs of
- Dense left-sided intervention, the localized signs clearing of inflammation
hemiplegia patient’s family will of infection on infection. and were
- GCS identify the 5 signs all the sites of 6. constant able to return
11(E4V1M6) of inflammation and incision or monitoring will demonstrate the
a return trauma. allow the nurse to care of a
demonstration of detect infection at
NAME: CRYSTAL JADE S. RESURRECCION
YEAR/SECTION: BSN 4Y2-2
care of tracheostomy 7. teach the family its primary stage tracheostomy on
of the patient the thus allowing for a dummy.
5 signs of prompt
inflammation. intervention.
8. teach the family 7. this will allow the
how to care for a caretaker to
tracheostomy easily spot the
and the infection in the
contraindications early stages in
for this case the nurse
accessory. didn’t notice.
9. Practice proper 8. this will prevent
aseptic infection and
technique when place the client at
changing less of a risk.
dressing or 9. This prevents
cleaning infections.
incision. Collaborative:
Collaborative: 1. this will prevent
10. Administer the start of
antibiotic infections and
prophylaxis as will fight the
ordered by microorganisms
the doctor.
NAME: CRYSTAL JADE S. RESURRECCION
YEAR/SECTION: BSN 4Y2-2
alongside the
immunity of the
patient.
NAME: CRYSTAL JADE S. RESURRECCION
YEAR/SECTION: BSN 4Y2-2
2. Make at least 3 DRUG STUDY use for this client.

NAME OF DRUG MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING

ACTION EFFECTS CONSIDERATION

Generic name: Increases osmotic - Test dose for Contraindicated to CNS: Keep I.V. calcium
pressure of marked patients with myocardial available to reverse
Mannitol glomerular filtrate, oliguria or damage, heart block or Toxicity magnesium
Brand name: thus inhibiting suspected coma. Flaccid paralysis intoxication.
tubular reabsorption inadequate
Osmitrol of water and renal Dizziness
electrolytes. Drug function. Respiratory paralysis Monitor renal
Therapeutic class: Weakness
elevates plasma - Oliguria function.
Diuretics osmolality and - To reduce Disappearance of patellar
increases urine intraocular reflex Tell patient to report
Pharmacologic output. pressure or all adverse effects.
class: Diminished deep tendon
cerebral
reflex
Osmotic Diuretics edema.
- Diuresis in
Dosage, route, drug
frequency: intoxication.
Adults and children
older than age 12:
200 mg/kg about 75
ml of a 20% IV
solution or 50 ml of
20% solution over 3
to 5 minutes.
Generic name: inhibits the sodium Acute pulmonary Contraindicated in CNS: Monitor weight, BP
and chloride edema patients with and pulse rate
Furosemide reabsorption at the hypersensitive to drug Dizziness routinely with long
proximal and distal Edema and in those with anuria. term use.
Brand name: Nausea
tubules and the hyperetension
Lasix Headache
NAME: CRYSTAL JADE S. RESURRECCION
YEAR/SECTION: BSN 4Y2-2
Therapeutic class: ascending loop of Drug may exacerbate or Tiredness Watch for signs of
henle. activate systemic lupus hypokalemia, such as
Anti-hypertensives erythematous. muscle cramps and
Pharmacologic muscle weakness.
class:
Loop diuretics
Dosage, route,
frequency:
Injection: 10mg/ml
Oral solution:
10mg/ml
Tablets: 20 mg
p.o

NAME OF DRUG MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE NURSING

ACTION EFFECTS CONSIDERATION

Generic name: Probably alters To prevent or Contraindicated if therapy CNS: Monitor baseline ecg,
chemical control mania in can’t be closely Nausea thyroid sulfates, renal
Lithium Carbonate transmitters in the bipolar disorder monitored. Fatigue studies and
Brand name: CNS, possibly by Restlessness electrolyte levels.
interfering with Use extreme caution in Dizziness
Carbolith ironic pump patients receiving Eeg changes Weight patient daily;
mechanisms in brain neuromuscular blockers check for edema or
Therapeutic class: and diuretics: elderly or sudden weight gain.
cells, and may
compete with or debilitated patients.
Antimanics
replace sodium ions.
Pharmacologic
class:
NAME: CRYSTAL JADE S. RESURRECCION
YEAR/SECTION: BSN 4Y2-2
Alkali metals
Dosage, route,
frequency:
Capsules 150 mg
Tablets 5,10,20,mg
P.O bid