Last updated on May 16th, 2022 at 07:24 pm
Increased ICP Nursing Care Plans Diagnosis and Interventions
Increased ICP NCLEX Review and Nursing Care Plans
Increased intracranial pressure (ICP) refers to the rise in the pressure around the brain or inside the skull. The increase in pressure could be due to an increase in the volume of fluid around the brain.
For instance, an injury or a ruptured tumor may increase the blood around the brain, or there is an increase in cerebrospinal fluid that naturally cushions the brain which may trigger an increase in the pressure inside the skull.
Increased ICP can also indicate that the brain tissue is swelling as a result of an injury or other medical conditions such as tumors, infections, or benign intracranial hypertension.
Furthermore, increased ICP can both cause and be the effect of brain damage. It is a life-threatening medical condition for which an individual who is experiencing symptoms should seek immediate medical attention.
Signs and Symptoms of Increased Intracranial Pressure
Increased ICP symptoms differ based on a person’s age. Infants with increased ICP may experience different symptoms than older children or adults, although the most frequent signs and symptoms of increased ICP are listed below.
- Hazy vision
- Reduced alertness
- Behavioral changes
- Difficulties in speech or movement
- Drowsiness or lack of energy
- Unusual reaction of pupils to light
- Changes in the shape of the head due to separation of skull sutures and soft plates, or bulging fontanel in infants
- Cushing’s triad – a term used to describe three symptoms that occur simultaneously and necessitates emergency medical attention. Interrupted breathing patterns, widening pulse pressure, and a decrease in heart rate are among the symptoms.
Increased ICP symptoms can mimic those of other illnesses or medical conditions, therefore a physician must confirm the diagnosis. If an individual’s ICP becomes too high, he or she may fall into a coma, resulting in brain damage if not treated immediately.
Causes of Increased Intracranial Pressure
Increased intracranial pressure is commonly caused by head trauma, although it can also be caused by other factors. Other causes that may contribute to an increase in ICP include:
- Brain tumors
- Collection of spinal fluid in the brain cavities known as hydrocephalus.
- Uncontrolled high blood pressure that can cause bleeding in the brain which is called hypertensive brain injury
- Hypoxemia or a lack of oxygen in the blood
- Inflammation of the protective membranes around the brain and spinal cord, known as meningitis.
- Certain medications
In general, too much fluid inside the skull or any form of inflammation or swelling in the brain causes the intracranial pressure to rise.
High ICP in babies, on the other hand, could be the outcome of child abuse, such as in the case of shaken baby syndrome. It is a type of brain injury that can occur when a person handles a baby or infant too harshly.
Diagnosis of Increased Intracranial Pressure
The physician may do the following tests and procedures to determine if the ICP is elevated:
- Medical history. If high ICP is suspected as the cause of symptoms, the physician will need to know several essential details about the patient’s family and personal medical history. The physician will inquire if the patient has lately experienced a concussion or has been diagnosed with a brain tumor. The patient must also supply a list of any medications or supplements that he or she is taking to the physician.
- Physical Examination. The doctor will then conduct a physical examination that includes an evaluation of the patient’s vital signs as well as a thorough neurological examination that includes mental state, pupil reactions, visual acuity, movement and coordination, reflexes, and speech.
- Spinal Tap. The cerebrospinal fluid pressure is measured by a spinal tap, commonly known as lumbar puncture.
- Computed tomography (CT) scan. The gold standard imaging test that produces a sequence of cross-sectional X-ray images of the head and brain.
- Magnetic resonance imaging (MRI) scan. It may be used after the initial procedures to evaluate a person’s brain tissue in greater detail or to identify the specific cause of increased ICP.
In severe cases of increased intracranial pressure (ICP), the physician may need to install an intrusive intracranial monitoring tool that will provide a direct reading using a catheter, bolt, or sensor placed inside the skull when there is a substantial increase in intracranial pressure which usually leads to severe condition.
This method of monitoring is found to be beneficial for measuring ICP, but it can also potentially develop problems such as further damage or infection.
Treatment for Increased Intracranial Pressure
The most important aim of the treatment for those with high ICP is to lower the pressure inside the skull. This can be accomplished in several ways, which include the following:
- Placing a shunt that drains the excess cerebrospinal fluid through a tiny hole in the skull or the spinal cord
- Lowering blood pressure with certain drugs such as diuretics and hypertonic saline
- Sedating the patient to alleviate anxiety and neurological responses
- Craniotomy or surgery for removing a portion of the skull to allow brain expansion without causing any damage
- Reducing damage by inhibiting the neurological function
- Lowering the general body temperature and slowing metabolism by inducing hypothermia
The next approach to managing increased ICP is to determine the underlying causes of the condition. If the elevated intracranial pressure was caused by an infection or stroke, the causal factors must be addressed in addition to the increased ICP.
Addressing the causative factors will keep the pressure from rising further.
Prevention of Increased Intracranial Pressure
Increased ICP may not always be preventable, however, it is feasible to lower the risk of several underlying issues that might lead to increased ICP, such as stroke, high blood pressure, or a head injury, by doing the following:
- Smoking cessation
- Blood sugar and cholesterol levels must be kept under control
- Regular physical activity
- Maintain a healthy weight.
- Avoiding medicines that may raise blood pressure
- Consuming a nutritious and well-balanced diet
- Lowering salt consumption
- Avoiding risky activities or extreme sports
- Wearing an appropriate helmet when riding a bike or a motorcycle
- Maintaining a seatbelt on when riding a car
- Keep floors dry and uncluttered at home to avoid falls, or install handrails as necessary
Key Points on Increased Intracranial Pressure
In almost every incidence, increased intracranial pressure implies a medical emergency. A blow to the head is the most common cause of high ICP, but no matter what causes the pressure to rise, it can result in brain damage and other severe complications if the pressure rises too high.
Factors like a physical transition of the brain on imaging scans, abnormal positioning/posturing of the extremities or body, progression of other neurologic complications such as diabetes insipidus or poor temperature control, poor pupil reactions, and a lack of basic neurological responses are all signs of significant complications from increased ICP and a poor prognosis.
This condition can occur as part of a chronic or congenital disorder, but when it occurs abruptly, prompt medical attention is required to avoid a fatal result. The initial goal of treatment is to relieve pressure on the brain tissue, lowering the risk of brain injury.
This illness can lead to seizures, comas, strokes, and brain damage if not treated properly.
Increased ICP can be fatal in severe situations, although prompt treatment can improve a person’s prognosis, and a full recovery is attainable with appropriate treatment.
Although increased ICP is not always prevented, some factors can be mitigated by lifestyle modifications. If a person has a severe headache, loses consciousness, or has other unexplainable neurological symptoms, receiving medical help as soon as possible is the safest approach to avoid fatal complications.
The earlier someone seeks treatment to relieve pressure on the brain, the better.
Nursing Diagnosis for Increased ICP
Increased ICP Nursing Care Plan 1
Ineffective Tissue Perfusion (Cerebral)
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to increased intracranial pressure (ICP) secondary to hydrocephalus as evidenced by restlessness, slow reflexes, bulging fontanel, and decreased respiration and pulse rates.
Desired Outcome: The patient’s brain function will improve as demonstrated by normal vital signs, increased alertness, and no further decrease in consciousness.
|Increased ICP Nursing Interventions||Rationale|
|Monitor vital signs every hour, observing any changes in respiration, heart rate, or rhythm, particularly measuring pulse pressure.||To detect early indicators of increased intracranial pressure such as erratic blood pressure, tachycardia, and rapid breathing, or Cushing’s triad.|
|Evaluate the mental state, motor, and balancing capacities, as well as the reflexes and cranial nerves.||These evaluations will assess whether or not a patient’s neurological conditions have changed as a result of ICP.|
|Pay attention to the quality and tone of the child’s cry.||Increased intracranial pressure might be signaled by a high-pitched cry.|
|Measure the circumference of the patient’s head and the anterior fontanelle’s appearance.||CSF buildup is demonstrated by an increasing head circumference or a tight bulging fontanelle.|
|Provide the patient with a non-stimulating atmosphere and appropriate relaxation periods.||Continuous stimulation and activity may raise intracranial pressure.|
|Maintain the client’s head in a neutral position by progressively elevating the head of the bed around 15-45 degrees as recommended.||This position will lower arterial pressure and improve cerebral perfusion by facilitating venous drainage.|
|Administer oxygen therapy as needed by the patient.||Supplemental oxygen improves the patient’s cerebral vasodilation and blood volume by preventing hypoxemia.|
|Administer diuretics and corticosteroids as ordered by the physician.||These medications may help to treat hydrocephalus by lowering CSF production and reducing inflammation.|
Increased ICP Nursing Care Plan 2
Nursing Diagnosis: Deficient Knowledge related to lack of exposure to information in increased intracranial pressure (ICP) as evidenced by request for information regarding drugs, and signs and symptoms of the condition.
Desired Outcome: The patient will exhibit awareness of the disease process, management, and prognosis as manifested by verbalizing proper information and asking suitable and relevant queries.
|Increased ICP Nursing Interventions||Rationale|
|Evaluate the patient’s intellectual capabilities and willingness to learn new information.||Increased ICP has been linked to memory impairment, as well as changes in behavior. It may be challenging and time-consuming to focus and learn new information for the patient.|
|Evaluate the patient’s understanding of the condition and treatment regimen.||Most patients and their families have never had exposure to increased ICP condition, especially if it was caused by an abrupt and unexpected incident like a head injury.|
|Inform the patient and family members about any changes in the patient’s health status on a regular basis.||Family members are important members of the medical team because they can supply significant data about the patient’s history prior to the condition.|
|Enable displays of concern as well as the opportunity to inquire about the condition of the patient and recuperation.||Allows an opportunity to obtain the information necessary to gain a better understanding of the patient’s condition.|
|Educate the patient/significant others about the purpose for the operation, the type of surgery to be performed, the surgery site and dressings, the time of surgery and length of the procedure, preoperative care, and any medications that may be required.||Provides details on the surgery, including the anticipated outcomes as well as any potential side effects.|
|Educate the patient and his or her family about the possibility of physical, occupational, and speech therapy, as well as continuous home support.||Rehabilitation can be a lot of work that extends beyond the hospitalization period. Patients and relatives should be informed that after the patient is discharged, their responsibilities as significant others may shift to lead caretaker roles. Families require assistance in adjusting to their new roles and circumstances.|
|Use drawings and illustrations, as well as videotapes, to explain the rationale for each treatment or type of therapy and what to anticipate.||These approaches make it easier to learn about the condition and gain a better grasp of it.|
|Address any misconceptions and respond to all questions honestly and in plain simple language.||Doing this can help prevent any misunderstandings, as well as incorrect information or beliefs regarding the condition.|
Increased ICP Nursing Care Plan 3
Risk for Injury
Nursing Diagnosis: Risk for Injury related to increased ICP.
Desired Outcome: The patient will recognize the factors that increase the risk of injury, will display injury-avoidance behaviors, and will remain injury-free within 8 hours of nursing intervention and management and during hospital stay.
|Increased ICP Nursing Interventions||Rationale|
|Perform a neurologic and vitals examination on the patient every 4 hours or as needed.||These tests reveal that the ICP is increasing, resulting in shallower breathing, increased blood pressure, and a faster pulse.|
|Inspect for a quickly expanding head circumference, tense, bulging fontanels, widening suture lines, irritability, lethargy, stiffness of the lower extremities, convulsions, a high-pitched cry, dilated scalp veins, and alterations in typical feeding patterns.||These findings suggest an increase in ICP in infants and small children.|
|Inform close family members about the signs and symptoms of increased ICP as well as how to report any changes to the doctor.||Encourages to be aware of the possibility of acquiring high ICP and to take precautionary steps.|
|Padding the crib/bed, removing toys and objects off the bed, keeping suction and oxygen by the bedside, and noting and reporting seizure characteristics as part of seizure precautions.||Prevents self-injury induced by increased ICP throughout seizure activity and treats apnea during seizure activity.|
|When handling or switching positions of the patient, elevate the head 30 degrees and support the head. Monitor also the skin integrity while changing positions.||Promotes CSF drainage and minimizes CSF accumulation; the infant may be unable to lift and move his or her head.|
|When holding the newborn, protect the enlarged head by holding it in one arm, position the infant on a pillow when moving, and lift the infant’s head and body simultaneously.||Protect the infant’s head against injury and the strain on his or her neck.|
|Advise significant others that the condition is chronic and that continuous monitoring and follow-up treatment are necessary.||Provides truthful and straight knowledge that fosters the infant’s or child’s ultimate health and purpose.|
|Monitor the patient’s electrolytes and urine outputIf the patient is on diuretics or hypertonic saline, this may cause sodium levels to vary, potentially resulting in seizures.|
Increased ICP Nursing Care Plan 4
Disturbed Sensory Perception
Nursing Diagnosis: Disturbed Sensory Perception related to increased intracranial pressure secondary to meningitis.
Desired Outcome: The patient will maintain a normal level of consciousness (LOC).
|Increased ICP Nursing Interventions||Rationale|
|Assess the level of consciousness of the patient using the Glasgow coma scale.||The Glasgow coma scale is a dependable and objective method of assessing motor, verbal, and sensory pieces of evidence that indicate the state of consciousness. The level of damage in meningitis can be determined with the help of a neurological evaluation.|
|Monitor and contact the doctor if the patient’s level of consciousness continues to deteriorate.||Once the LOC drops even lower, further or different treatment may be mandated by the physician. Elevated ICP with lower cerebral perfusion pressure may be evidenced by changes in mental status, seizures, increased blood pressure, bradycardia, or breathing problems.|
|Watch out for indicators of cerebral edema in the patient, such as dizziness, headaches, abnormal breathing, neck pain, nausea, or vomiting.||As the symptoms worsen, anoxia, vasodilation, or vascular stasis can cause cerebral edema caused by an increase in intracellular and extracellular fluid in the brain.|
|Evaluate the patient’s ability to follow basic or complex directions.||When one of the cerebral hemispheres is affected, cognitive performance suffers.|
|Assess the existence or lack of protective reflexes in the patient, such as the swallow, gag, blink, and cough reflexes.||The absence of reflexes is a late symptom of escalating ICP.|
|Raise the head of the bed 30° to 45° while keeping the client’s head in a neutral position.||Helps to reduce ICP by promoting venous outflow from the brain.|
|As necessary, reorient the client to his or her surroundings.||The importance of regular reality orientation in promoting cognitive performance cannot be overstated.|
|Assist the patient with diagnostic procedures, such as an electroencephalogram, a lumbar puncture for CSF, a magnetic resonance imaging (MRI), a computed tomography (CT) scan, or a ventriculogram.||These diagnostic procedures are used to determine cerebral pressure and the presence of potential pathogens.|
|Establish seizure precautions by constantly observing and caring for the person who is having a seizure.||During a seizure attack, providing proper and thorough care reduces complications and further brain injury.|
|Maintain a calm atmosphere and dim the lights for the patient.||Prevents stimulus from causing or precipitating a convulsion episode in the patient.|
|During the first 24 hours, measure the patient’s pupil size every 3 hours, then every 6 hours.||Pupil diameters will be inconsistent as a result of increased intracranial pressure, with a fixed dilated pupil.|
Increased ICP Nursing Care Plan 5
Nursing Diagnosis: Acute Pain related to increased intracranial pressure (ICP) secondary to meningitis as evidenced by headache, restlessness, neck discomfort, and nuchal rigidity.
Desired Outcome: The patient will demonstrate feelings of comfort and pain relief after the implementation of nursing interventions and management.
|Increased ICP Nursing Interventions||Rationale|
|Determine whether the patient has a headache or is photophobic.||Infection of the brain’s meninges can induce inflammation, which can cause severe headaches and hypersensitivity to bright lights.|
|Examine for discomfort and resistance during passive knee extension with the hips fully flexed, also known as Kernig’s sign, and Brudzinski’s sign, in which the hips flex when the head is bowed forward.||These are used to look for any signs of inflammation in the meninges.|
|Keep guests at a minimum to avoid stimulating the patient.||Stimulation can raise intracranial pressure, making the pain of the patient worse.|
|Control the surroundings of the patient to promote rest.||Sensory overload is caused by environmental changes such as increased noise and glaring light, which leads to cerebral inflammation and convulsions.|
|Turn the patient frequently and carefully reposition the patient.||Reduces the patient’s irritability and agitation by promoting comfort.|
|Assist the patient with ROM exercises.||Prevent the patient’s joint stiffness and neck discomfort.|
|As directed by the physician, administer antibiotics and corticosteroids.||Antibiotics and corticosteroids are used to reduce inflammation and, as a result, the patient’s pain.|
|Administer analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) as directed by the doctor.||These medications are used to alleviate the patient’s pain.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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