Create your own awesome maps

Even on the go

with our free apps for iPhone, iPad and Android

Get Started

Already have an account?
Log In

Increased Intracranial Pressure by Mind Map: Increased
Intracranial Pressure
5.0 stars - 1 reviews range from 0 to 5

Increased Intracranial Pressure

 17 year old male  who plays football at the High School level has presented to the emergency department with altered level of consciousness.   Has a history of three epsiodes of loss of consciousness.     Source:  Lewis, S. (2007).  Medical-surgical nursing:  Assessment and management of clinical problems (7th ed.). Philadelphia, PA: Mosby Elsevier.  

Nursing

The overall goals are that the patient with increased ICP will have ICP within normal limits, maintain a patent airway, demonstrate normal fluid and electrolyte balance, and have no complications secondary to immobility and decresed LOC

maintenance of respiratory function

airway

positioning

no suctioning/coughing

abdominal distention

ABGs

fluid and electrolyte balance

I&O, daily weights

glucose, Na+, K+

monitoring of intracranial pressure

ventriculostomy

body position

HOB up

slow and gentle

avoid valsalva maneuvers

avoid extreme hip flexion

protection from injury

confusion, agitation

seizure percautions

avoid restraints

quiet nonstimulating environment

family presence

psychologic considerations

simple explanations

support

education

Pathophysiology

brain tissue

blood

cerebrospinal fluid

Assessment

change in level of consciousness

change in vital signs

Cushings Triad, increasing systolic pressure, bradycardia, irregular respiratory pattern

ocular signs

decrease in motor function

headache

vomiting

Diagnostics

computed tomography (CT) scan

magnetic resonance imaging (MRI)

skull and spinal x-ray studies

electroencephalogram (EEG)

angiography

laboratory studies

complete blood count (CB)

coagulation profile

electrolytes

arterial blood gases (ABGs)

ammonia level

general drug and toxicology screen

CSF protein, lumbar puncture

Nursing Diagnoses

Ineffective tissue perfusion (cerebral)

Decreased intracranial adaptive capacity

Risk for disuse dyndrome

Interupted family processes

Collaborative Care

The goals of management are to identify and treat the underlying cause of increased ICP and to support brain function.

oxygenation

ABG analysis guides therapy, endotracheal intubation, mechnical ventilation

drug therapy

osmotic diuretics

corticosteroids

high-dose barbiturates

hyperventilation therapy

target CO2 to 30-35 mm Hg

nutritional therapy

enteral nutrition

parenteral nutrition

fluid therapy - keep normovolemic