Nursing diagnosis – DECREASED INTRACRANIAL ADAPTIVE CAPACITY

ADAPTIVE  CAPACITY

DEFINITION

Intracranial fluid dynamic mechanisms that normally compensate for

increases in intracranial volumes are compromised, resulting in

repeated disproportionate increases in intracranial pressure (ICP) in

response to a variety of noxious and nonnoxious stimuli

DEFINING CHARACTERISTICS

• Baseline ICP    10 mm Hg

• Disproportionate increase in ICP following single nursing

maneuver

• Elevated P2 ICP wave form

• Repeated increase of   10 mm Hg for more than 5 min following

external stimuli

• Volume pressure response test variation (volume–pressure ratio

greater than 2, pressure–volume index   10)

• Wide amplitude ICP waveform

RELATED FACTORS

• Brain injuries

• Sustained hypotension with

• Decreased cerebral perfusion

intracranial hypertension

• Sustained increased ICP

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac functioning

• Neurocognition

• Comfort

• Pharmacologic function

• Elimination

• Respiratory functioning

• Fluid and electrolytes

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Maintain effective breathing pattern and normal ABG levels.

• Show no evidence of fever.

• Modify environment to eliminate noxious stimuli.

• Maintain regular bowel function.

• Maintain skin integrity.

• Remain free of signs and symptoms of infection.

• Not show evidence of neurological compromise.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Neurological Status:

Consciousness; Wound Healing: Primary Intention

INTERVENTIONS AND RATIONALES

Determine: Assess vital signs, temperature, pulses, heart sounds,

jugular vein distension; electrocardiogram, history of hypertension;

mental status, reflexes, response to pain, papillary size and response

to light; respiratory rate, depth, and pattern of respiration, ABG,

pulse oximetry; monitor ICP wave forms for trends over time. Mon-

itor for damped waves. Assess cerebral perfusion pressure.

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Assessment information will assist in identifying appropriate

interventions.

Perform: Maintain ICP monitoring systems if used. Careful attention

must be paid to ensure that the system is functioning to provide

accurate information. Use sterile technique for dressing changes to

prevent contamination of equipment and infection.

Maintain a patent airway and suction only if needed. Suctioning

stimulates coughing and Valsalva maneuver; Valsalva increases

intrathoracic pressure, decreases cerebral venous drainage, and

increases cerebral blood volume, resulting in increased ICP. Elevate

head of the bed 15 –30   or as ordered, and use sandbags, rolled

towels, or small pillows to keep head in a neutral position. Reposi-

tion patient by using a draw sheet to prevent atrophy. Use minimal

amount of stimuli when caring for the patient. Turn and reposition

patient every 2 hr to prevent atelectasis.

Perform ROM exercises to maintain muscle tone.

Inform: Teach patient and family those aspects of care in which they

can participate without feeling anxious. Instruct family members in

gentle stroking of patient’s face, arms, or hand. Touch by family

members may lower the ICP in some cases.

Attend: Provide nursing care in a calm, reassuring manner. Avoid

discussion of upsetting topics near the bedside. This helps prevent

emotional upset that can increase ICP. Encourage patient and family

to express feelings associated with diagnosis, treatment, and recov-

ery. Expression of feelings helps patient and family cope with treat-

ment.

Manage: Arrange for frequent multidisciplinary/family care

conference in order to keep care goal-oriented. Refer patient and

family to support group to help deal with the injury, diagnosis, or

recovery. Refer to social worker/case manager for follow-up care,

home assessment, home visits, and referral to community agencies.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Bedside Laboratory Testing; Cerebral

Edema Management; Fluid–Electrolyte Management; ICP Monitoring

Reference

Littlejohns, L., & Bader, M. K. (2005, October–December). Prevention of sec-

ondary brain injury: Targeting technology. AACN Clinical Issues, 16(4),
501–514.

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