Nursing Care Plan

Outcome/Short Term Patient Centered Goals

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

Patient will have intracranial  pressure within normal range.

  Monitor patient’s neurologic status, ICP and vital signs at least every hour.
  Notify physician for collaborative management or institute a protocol to respond to a sustained ICP greater than 20.
   Maintain patient’s head of the bed at 30 degrees elevation or higher and patient’s body in a neutral position. Do not allow pronounced neck or hip flexion.
  Monitor the patient’s temperature and maintain it within designated parameters, aggressively treat hyperthermia.
   Monitor patient’s blood gases, collaborate with physician and respiratory therapist to resolve hypercarbia, hypocarbia, or hypoxia. 
  Suction only after preoxygenating the patient and for less than 10 seconds at a time.
   Spread nursing activities out, do not cluster them

It is imperative to identify when the patient’s ICP is increasing and to institute collaborative measures to decrease it.  Intracranial pressure increases may also be limited by enhancing venous drainage from the head, maintaining the patient in a normothermic state, preventing episodes of hypercarbia, hypocarbia and hypoxia as well as allowing the patient a chance to rest and the ICP to return to baseline between activities. 

ICP will remain less than 20 (preferably less than 15).

Glasgow Coma Scale will be 13 or higher.

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

Patient will have a cerebral perfusion pressure (CPP) of at least 50 preferably 60. 

 Monitor the patient’s blood pressure.  Notify the physician or institute a management protocol should the systolic BP fall below 90 mm Hg.
  Notify the physician for a BP greater than 180 systolic.
  Calculate the mean arterial pressure (MAP) and the CPP.
When CPP is decreased institute either methods to decrease ICP (see above) or increase MAP.
  Collaborative measures to increase MAP may include NS   or RL infusion or possibly hypertonic saline. 

Maintenance of a systolic pressure of at least 90 is only one of several factors necessary to maintain adequate perfusion of the brain.  A CPP less than 50 should be avoided since it is associated with loss of autoregulation of the brain and poor patient outcomes. 

CPP= 60

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

Client will not aspirate.

 Maintain head of bed elevated higher than 30 degrees.
 If patient is intubated, maintain ETT cuff pressure at 25 mmHg, if possible suggest the use of an ETT with continuous subglottic suctioning (CASS) tube.
  Provide mouth care per policy.
   Assure proper placement of a feeding tube and assess gastrointestinal functioning prior to and during feeding.
 

  Positioning the patient with the head of the bed elevated has been shown to be an effective part of the ventilator bundle at reducing aspiration and pneumonia. 
  The use of a CASS tube and provision of mouth care may decrease the incidence of aspiration of bacteria.

 Proper placement of the tube and assurance that there are not excessive residuals limits the possibility of aspiration.

Chest x-ray, lung sounds and arterial blood gases  normal or at patient’s baseline.