Ncp - Decreased Intracranial Adaptive Capacity R/t Space- Occupying Lesion.

ASSESSMENT

NURSING DIAGNOSIS

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Decreased Intracranial Adaptive Capacity r/t SpaceOccupying Lesion.

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Altered mental status Speech abnormalities Restlessness Changes in mental state AEB (-) pupil reaction to light, flexion on pain, no verbal response.

SCIENTIFIC EXPLANATION Intracranial pressure, (ICP), is the pressure exerted by the cranium on the brain tissue, cerebrospinal fluid (CSF), and the brain's circulating blood volume. ICP is a dynamic phenomenon constantly fluctuating in response to activities such as exercise, coughing, straining, arterial pulsation, and respiratory cycle. An increase in pressure, most commonly due to head injury leading to intracranial hematoma or cerebral edema can crush brain tissue, shift brain structures, contribute to hydrocephalus, cause the brain to herniate, and restrict blood supply to the brain, leading to an ischemic cascade. If left untreated the patient may result to coma or worst death.

PLANNING

INTERVENTIONS

Short term:

>Establish rapport

After 1-2° of NI the SO will be able to understand the client’s condition and be able perform actively in promoting the clients condition having now a higher level of understanding of the client’s condition and complications that may occur.

>Monitor VS. >Monitor/document changes in ICP waveform and responses to stimuli. >Assess eye opening and position/movement, Pupils (size, equality, light reactivity), purposeful and nonpurposeful motor response comparing left and right sides, presence of reflexes, nuchal rigidity, consciousness and mental state. >Provide information about the client’s condition including the complications which may arise once untreated

Long term: After 6-7 days of NI the client will be able to demonstrate stable ICP AEB normalization of pressure waveforms/response to stimuli.

>Elevate HOB and maintain head/neck in midline/neutral position >Decrease extraneous stimuli/provide comfort measures >Limit activities that increases intrathoracic/abdominal pressure >Administer medications as ordered (e.g. antihypertensives, diuretics, analgesics, antipyretics, vasopressors, antiseizure, neuromuscular blocking agents, and corticostreiods) >Prepare pt. for surgery as indicated (Space Occupying Lesion) >Refer accordingly

RATIONALE >To gain the client and SO’s trust. >To obtain data for comparison. >To alter care appropriately. > To note degree of impairment

>To increase SO’s understanding of the client’s condition and will be able to decide properly for the client’s care. >To promote circulation/venous drainage >To reduce CNS stimulation and promote relaxation. >To decrease factors which may contribute in further increasing ICP. >To pharmacologically manage client’s condition and maintain homeostasis

>To reduce ICP and enhance circulation >To have a continuous client’s care

EXPECTED OUTCOME The SO shall have understand the client’s condition and be able perform actively in promoting the clients condition having now a higher level of understanding of the client’s condition and complications that may occur. The client shall have demonstrated stable ICP AEB normalization of pressure waveforms/response to stimuli.