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
• Baseline ICP 10 mm Hg
• Disproportionate increase in ICP following single nursing
• Elevated P2 ICP wave form
• Repeated increase of 10 mm Hg for more than 5 min following
• Volume pressure response test variation (volume–pressure ratio
greater than 2, pressure–volume index 10)
• Wide amplitude ICP waveform
• Brain injuries
• Sustained hypotension with
• Decreased cerebral perfusion
• Sustained increased ICP
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac functioning
• Pharmacologic function
• Respiratory functioning
• Fluid and electrolytes
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.
Assessment information will assist in identifying appropriate
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-
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
Littlejohns, L., & Bader, M. K. (2005, October–December). Prevention of sec-
ondary brain injury: Targeting technology. AACN Clinical Issues, 16(4),