Page 253 - Critical Care Nursing Demystified

238 CRITICAL CARE NURSING DeMYSTIFIED

Nursing Care of the Patient to Decrease ICP

Nursing Diagnoses for the Patient With
Increased ICP and ICP Monitoring Expected Outcomes
4 Tissue perfusion, altered, cerebral The ICP will be <90 mm Hg
The CPP will be <14 mm Hg
4 Risk for infection The patient will have a normal tem-
perature
The CSF will be clear, colorless

Nursing Interventions
1. Assess baseline vital signs to observe for signs of increased ICP, which
include hyperthermia, bradycardia, respiratory changes, and widening of
the pulse pressure.

2. Balance the transducer at the level of the foramen of Monroe by using
the tragus of the ear and the top of the transducer to make trending
readings consistent.
3. Calibrate the transducer according to manufacturer’s/hospital protocols Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
to ensure consistency in trended readings.
4. Monitor and record the MAP, CPP, and ICP, especially in response to
nursing care to determine early signs of increased ICP that can occur
with patient procedures like suctioning.
5. Consult neurologist if abnormal changes occur to treat the patient early
and prevent complications.
6. Monitor the system for air bubbles; disconnect and purge if needed. Air
bubbles could enter the brain, creating an embolism, and can dampen
waveforms.
7. Monitor the insertion site for bleeding, edema, leakage of CSF, and infec-
tion to prevent complications.
8. Perform baseline and ongoing neurological assessments.
9. Position the patient with the head of the bed elevated at least 30 degrees,
keeping the bed in lock-out to ensure this. This promotes cerebral venous
drainage by gravity.
10. Keep the patient’s head and neck midline to decrease ICP by promoting
drainage from the head through the jugular veins.