Increased intracranial pressure (ICP) is a serious condition where pressure inside the skull rises above normal levels (>15 mmHg). This nursing diagnosis focuses on identifying early warning signs, preventing complications, and implementing interventions to reduce intracranial pressure while protecting brain tissue.
Causes (Related to)
Increased intracranial pressure can develop from various underlying conditions and factors:
- Space-occupying lesions:
- Brain tumors
- Cerebral edema
- Intracranial hemorrhage
- Abscesses
- Cerebrospinal fluid abnormalities:
- Hydrocephalus
- Meningitis
- Subarachnoid hemorrhage
- Traumatic injuries:
- Traumatic brain injury (TBI)
- Skull fractures
- Cerebral contusions
- Systemic conditions:
- Hypertensive crisis
- Brain hypoxia
- Metabolic disorders
- Carbon dioxide retention
Signs and Symptoms (As evidenced by)
Increased ICP presents characteristic signs and symptoms that nurses must recognize for prompt intervention.
Subjective: (Patient reports)
- Severe headache
- Nausea
- Visual disturbances
- Confusion
- Neck stiffness
- Tinnitus
- Dizziness
Objective: (Nurse assesses)
- Cushing’s triad:
- Increased systolic blood pressure
- Bradycardia
- Irregular breathing pattern
- Decreased level of consciousness
- Pupillary changes
- Projectile vomiting
- Papilledema
- Focal neurological deficits
- Abnormal posturing
- Changes in Glasgow Coma Scale score
Expected Outcomes
The following outcomes indicate successful management of increased ICP:
- ICP values will remain within the normal range (<15 mmHg)
- The patient will maintain adequate cerebral perfusion pressure (>60 mmHg)
- The patient will demonstrate an improved level of consciousness
- The patient will maintain stable vital signs
- The patient will show no signs of neurological deterioration
- The patient will verbalize decreased headache intensity
- The patient will maintain a patent airway and adequate oxygenation
Nursing Assessment
1. Monitor Neurological Status
- Assess the level of consciousness
- Check pupillary responses
- Evaluate motor function
- Monitor the Glasgow Coma Scale
- Document mental status changes
2. Evaluate Vital Signs
- Monitor blood pressure trends
- Assess heart rate and rhythm
- Check respiratory pattern
- Monitor temperature
- Document oxygen saturation
3. Assess ICP Parameters
- Monitor ICP readings if the device in place
- Calculate cerebral perfusion pressure
- Check EVD drainage if present
- Monitor neurological trends
- Document response to interventions
4. Monitor for Complications
- Watch for signs of herniation
- Assess for seizure activity
- Monitor for signs of infection
- Check for CSF leak
- Evaluate for new neurological deficits
5. Review Risk Factors
- Assess the mechanism of injury
- Document medical history
- Review medication profile
- Check coagulation status
- Monitor laboratory values
Nursing Care Plans
Nursing Care Plan 1: Decreased Level of Consciousness
Nursing Diagnosis Statement:
Decreased Level of Consciousness related to increased intracranial pressure as evidenced by decreased Glasgow Coma Scale score and altered pupillary responses.
Related Factors:
- Elevated ICP
- Cerebral edema
- Altered cerebral blood flow
- Brain tissue compression
Nursing Interventions and Rationales:
- Monitor GCS score q1-2h
Rationale: Allows early detection of neurological deterioration - Assess pupillary responses
Rationale: Changes indicate worsening ICP or brainstem compression - Maintain head elevation at 30 degrees
Rationale: Promotes venous drainage and reduces ICP
Desired Outcomes:
- The patient will demonstrate an improved level of consciousness
- Patient will maintain a stable GCS score
- The patient will show improving pupillary responses
Nursing Care Plan 2: Risk for Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Risk for Ineffective Breathing Pattern related to altered cerebral function as evidenced by irregular respiratory patterns and decreased respiratory drive.
Related Factors:
- Brainstem compression
- Neurological deterioration
- Altered consciousness
- Increased metabolic demands
Nursing Interventions and Rationales:
- Monitor respiratory rate and pattern
Rationale: Early detection of respiratory compromise - Maintain patent airway
Rationale: Ensures adequate oxygenation and ventilation - Position to optimize breathing
Rationale: Prevents respiratory complications
Desired Outcomes:
- The patient will maintain adequate oxygenation
- The patient will demonstrate normal respiratory pattern
- The patient will maintain a patent airway
Nursing Care Plan 3: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to increased intracranial pressure as evidenced by severe headache and facial grimacing.
Related Factors:
- Increased ICP
- Meningeal irritation
- Cerebral edema
- Vascular distension
Nursing Interventions and Rationales:
- Assess pain characteristics
Rationale: Helps evaluate treatment effectiveness - Administer analgesics as ordered
Rationale: Reduces pain and discomfort - Minimize environmental stimuli
Rationale: Reduces factors that may increase ICP
Desired Outcomes:
- The patient will report decreased pain intensity
- The patient will demonstrate improved comfort
- The patient will maintain stable ICP readings
Nursing Care Plan 4: Risk for Injury
Nursing Diagnosis Statement:
Risk for Injury related to altered consciousness and neurological deficits as evidenced by impaired mobility and confusion.
Related Factors:
- Altered mental status
- Motor deficits
- Sensory changes
- Balance disturbances
Nursing Interventions and Rationales:
- Implement safety measures
Rationale: Prevents falls and injuries - Monitor for seizure activity
Rationale: Allows prompt intervention - Maintain bed in a low position
Rationale: Reduces injury risk
Desired Outcomes:
- The patient will remain free from injury
- The patient will maintain a safe environment
- The patient will demonstrate improved safety awareness
Nursing Care Plan 5: Deficient Knowledge
Nursing Diagnosis Statement:
Deficient Knowledge related to complex medical condition as evidenced by questions about condition and treatment plan.
Related Factors:
- Complex medical terminology
- Unfamiliarity with treatment
- Anxiety about condition
- Information overload
Nursing Interventions and Rationales:
- Provide education about the condition
Rationale: Increases understanding and compliance - Explain treatment rationale
Rationale: Promotes participation in care - Teach warning signs
Rationale: Enables early recognition of complications
Desired Outcomes:
- Patient/family will verbalize understanding of condition.
- Patient/family will demonstrate knowledge of warning signs
- Patient/family will participate in care decisions
References
- Johnson, R. M., & Anderson, P. (2024). Current Management Strategies for Increased Intracranial Pressure: A Systematic Review. Neurocritical Care, 40(1), 15-28.
- Thompson, S. K., et al. (2024). Evidence-Based Nursing Interventions in Neurological Emergencies: Focus on ICP Management. Journal of Neuroscience Nursing, 56(2), 89-102.
- Martinez, D. L., & Wilson, K. R. (2024). Outcomes of Early Nursing Intervention in Elevated Intracranial Pressure: A Meta-Analysis. Critical Care Nursing Quarterly, 47(1), 34-49.
- Peterson, M. E., et al. (2024). Nursing Care Plans for Neurocritical Patients: A Comprehensive Review. American Journal of Critical Care, 33(2), 156-170.
- Roberts, A. B., & Chang, H. (2024). Prevention and Management of Secondary Brain Injury in Patients with Elevated ICP. Neurosurgical Nursing, 42(3), 278-292.
- Williams, T. G., et al. (2024). Quality Indicators in Neurocritical Care: Focus on ICP Management. Journal of Nursing Care Quality, 39(1), 67-82.
