Neuro : Nursing interventions in

the prevention of increased ICP

CCNS 6124
CCN/1/2021/003
NOR HAFIZAH BINTI BADIOZAMAN

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NURSING INTERVENTIONS

1. Access neurological status hourly using

GCS to detect early changes indicative of
increased ICP
2. Monitor patient vital signs such as
bradycardia, bradypnea and high systole
BP (Cushing’s Triad) which may indicate
high ICP
3. Maintain the CPP > 60mmHg and ICP <
20mmHg to ensure adequate cerebral
perfusion
4. Elevate the head of bed 30-45° to
improve venous drainage of the brain

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5. Maintain patent airway to ensure
adequate cerebral oxygenation
o Maintain head alignment in neutral
position because hyperextension,
rotation or hyperflexion of the neck
causes decreased venous return
o Perform suction PRN and discourage
patient to coughing and gagging because
can increase ICP. Suctioning should not
more than 10 seconds
o Hyper-oxygenated patient before and
after suction to maintain adequate
oxygenation

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o Monitor ABG closely as per order to
ensure PaO2 > 100mmHg and
maintain adequate cerebral blood
flow
o Monitor PaCO2 level, 30-40mmHg if
hyperventilation therapy has done.
Hyperventilation therapy can cause
cerebral vasoconstriction and
decrease cerebral blood flow then
will reduce ICP

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6. Avoid activities that induce ICP
o Avoid extreme hip flexion to prevent
increases intrathoracic pressure
o Nurse patient in dim light, minimal noise
level and minimize or group the
procedures to reduce stimulant
o Avoid to restrained patient because it
will cause patient more anxiety
o Prevent hyperthermia and shivering
which can increase metabolic demand
and vasodilation

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7. Check HGT 2-3 hourly as per order to
maintain blood glucose 6-10mmol/L
because hyperglycaemia will increase
cerebral metabolic rate and increase ICP
8. Maintain fluid balance via accurate
intake output chart because
overhydration may lead to cerebral
oedema
9. Continue IVI NaCl 0.9% as per order to
maintain euvolemia and prevent
hypotension
10. Dilute the medications using IV NaCl
0.9%, avoid using Dextrose 5% because
can increase risk of cerebral oedema
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11. Medications
o Serve Tab PCM 1gm (anti-pyretic) as prescribed to bring down temperature
and prevent shivering
o Administer IV Maxalon 10mg (anti-emetic) if patient had nausea and
vomiting to prevent increase in intrathoracic pressure
o Administer stool softener to avoid patient straining and prevent
constipation that may cause increase in ICP
o Serve IV Lasix (loop diuretic) as prescribed if ICP > 20mmHg. Loop diuretic
able to reduce cellular volume and reduce cerebral edema
o IVI Mannitol may be prescribed at 0.25–1.0 g/kg if ICP > 20mmHg
persistently. Osmotic therapy may be used to expand blood volume by
shifting fluid from the brain’s extracellular to intravascular spaces

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o Start IVI Labetalol as per order if persistently high BP because it can
increase ICP, decrease cerebral blood flow or worsen bleeding
o Serve IV Dilantin (anti-convulsant) as per order to decrease the chance of
patient having seizure
o Doctor may start hypnotic agent to deepen sedation, such as IVI
Midazolam and IVI Morphine to reduce patient agitated and pain that can
cause increase ICP
o Use appropriate muscle relaxation as per order, for example IVI Atracurium
(0.5 mg/kg) to help reduce muscle activity and for cerebral protection
o Serve the Tab Pentobarbital (Barbiturate) as prescribed to reduce cerebral
metabolic demand and blood flow, providing cerebral protection