Outcomes (NOC)	Interventions (NIC) and Rationales
Neurologic Status • Cognitive status _____ • Cranial, sensory, and motor function _____ • Intracranial pressure _____ • Breathing pattern _____ • Pulse pressure _____ • Blood pressure _____ • Radial pulse rate _____ • Communication appropriate to situation _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Cerebral Edema Management • Monitor vital signs and neurologic status closely and compare with baseline to evaluate patient’s response to treatment and enable immediate reporting and modification of treatment if necessary. • Monitor respiratory status: rate, rhythm, depth of respirations; PaO₂, PaCO₂, pH, bicarbonate because low PaO₂ and a high hydrogen ion concentration (acidosis) are potent cerebral blood vasodilators that increase cerebral blood flow and may increase ICP. • Analyze ICP waveform to provide an accurate indicator of ICP. • Monitor patient’s ICP and neurologic responses to care activities. • Position with head of bed up 30 degrees or greater to promote venous drainage from head, reducing ICP. • Limit suction passes to <10 sec to prevent increased ICP. • Allow ICP to return to baseline between nursing activities to prevent sustained increases in ICP. • Maintain normothermia as elevated temperature increases cerebral metabolism and causes increased ICP. • Give sedation to decrease agitation and hyperactivity that cause increased ICP. • Decrease stimuli in patient’s environment to prevent increases in ICP

Outcomes (NOC)

Interventions (NIC) and Rationales

Neurologic Status

• Cognitive status _____

• Cranial, sensory, and motor function _____

• Intracranial pressure _____

• Breathing pattern _____

• Pulse pressure _____

• Blood pressure _____

• Radial pulse rate _____

• Communication appropriate to situation _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Cerebral Edema Management

• Monitor vital signs and neurologic status closely and compare with baseline to evaluate patient’s response to treatment and enable immediate reporting and modification of treatment if necessary.

• Monitor respiratory status: rate, rhythm, depth of respirations; PaO₂, PaCO₂, pH, bicarbonate because low PaO₂ and a high hydrogen ion concentration (acidosis) are potent cerebral blood vasodilators that increase cerebral blood flow and may increase ICP.

• Analyze ICP waveform to provide an accurate indicator of ICP.

• Monitor patient’s ICP and neurologic responses to care activities.

• Position with head of bed up 30 degrees or greater to promote venous drainage from head, reducing ICP.

• Limit suction passes to <10 sec to prevent increased ICP.

• Allow ICP to return to baseline between nursing activities to prevent sustained increases in ICP.

• Maintain normothermia as elevated temperature increases cerebral metabolism and causes increased ICP.

• Give sedation to decrease agitation and hyperactivity that cause increased ICP.

• Decrease stimuli in patient’s environment to prevent increases in ICP

Nursing Diagnosis

Risk for ineffective cerebral tissue perfusion related to reduction of venous and/or arterial blood flow and cerebral edema

Patient Goal

Maintains cerebral perfusion within normal parameters

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Perfusion: Cerebral • Intracranial pressure _____ • Systolic blood pressure _____ • Diastolic blood pressure _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviations from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range • Headache _____ • Restlessness _____ • Impaired cognition _____ • Decreased level of consciousness _____ • Vomiting _____ • Impaired neurological reflexes _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Cerebral Perfusion Promotion • Consult with physician to determine hemodynamic parameters, and maintain hemodynamic parameters within this range. • Induce hypertension with volume expansion or inotropic or vasoconstrictive agents, as ordered, to maintain hemodynamic parameters and maintain/optimize cerebral perfusion pressure (CPP). • Consult with physician to determine optimal head of bed placement (e.g., 0, 15, or 30 degrees) and monitor patient’s responses to head positioning. • Monitor determinants of tissue oxygen delivery (e.g., PaCO₂, SaO₂, and hemoglobin levels and cardiac output), if available, to ensure adequate oxygenation to support brain function. • Calculate and monitor CPP to evaluate adequacy of cerebral blood perfusion. • Monitor neurologic status to determine hemodynamic status. • Monitor intake and output to assess effects of diuretic and corticosteroid therapy. Intracranial Pressure (ICP) Monitoring • Record ICP pressure readings to monitor trends in cerebral pressure. • Monitor amount, rate, and characteristics of cerebrospinal fluid (CSF) drainage. • Prevent device dislodgment by securing system to patient. • Maintain sterility of monitoring system to prevent infection. • Change transducer, flush system and drainage bag as indicated to maintain system function. • Monitor insertion site for infection or leakage of fluid to prevent unreliable monitoring results. • Notify physician for elevated ICP that does not respond to treatment protocols

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Perfusion: Cerebral

• Intracranial pressure _____

• Systolic blood pressure _____

• Diastolic blood pressure _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviations from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

• Headache _____

• Restlessness _____

• Impaired cognition _____

• Decreased level of consciousness _____

• Vomiting _____

• Impaired neurological reflexes _____

Cerebral Perfusion Promotion

• Consult with physician to determine hemodynamic parameters, and maintain hemodynamic parameters within this range.

• Induce hypertension with volume expansion or inotropic or vasoconstrictive agents, as ordered, to maintain hemodynamic parameters and maintain/optimize cerebral perfusion pressure (CPP).

• Consult with physician to determine optimal head of bed placement (e.g., 0, 15, or 30 degrees) and monitor patient’s responses to head positioning.

• Monitor determinants of tissue oxygen delivery (e.g., PaCO₂, SaO₂, and hemoglobin levels and cardiac output), if available, to ensure adequate oxygenation to support brain function.

• Calculate and monitor CPP to evaluate adequacy of cerebral blood perfusion.

• Monitor neurologic status to determine hemodynamic status.

• Monitor intake and output to assess effects of diuretic and corticosteroid therapy.

Intracranial Pressure (ICP) Monitoring

• Record ICP pressure readings to monitor trends in cerebral pressure.

• Monitor amount, rate, and characteristics of cerebrospinal fluid (CSF) drainage.

• Prevent device dislodgment by securing system to patient.

• Maintain sterility of monitoring system to prevent infection.

• Change transducer, flush system and drainage bag as indicated to maintain system function.

• Monitor insertion site for infection or leakage of fluid to prevent unreliable monitoring results.

• Notify physician for elevated ICP that does not respond to treatment protocols

Nursing Diagnosis

Risk for disuse syndrome related to altered level of consciousness, immobility, and altered nutritional intake

Patient Goal

Experiences no complications of immobility

Outcomes (NOC)	Interventions (NIC) and Rationales
Immobility Consequences: Physiologic • Lung congestion _____ • Pneumonia _____ • Pressure sore(s) _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None • Nutritional status _____ • Joint movement _____ • Muscle tone _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Airway Management • Position patient to maximize ventilation potential to prevent aspiration and tongue from blocking airway. • Remove secretions by encouraging coughing or by suctioning to remove accumulated secretions, reduce risk of aspiration, and ensure patent airway. • Perform chest physical therapy to mobilize secretions and prevent pulmonary congestion. Pressure Ulcer Prevention • Use an established risk assessment tool to monitor individual’s risk factors (e.g., Braden scale [see eTable 12-3 on website]). • Inspect skin over bony prominences and other pressure points at least daily when repositioning to identify potential or actual skin problems and initiate a plan of care. • Turn every 1-2 hr as appropriate as prolonged pressure decreases circulation and leads to tissue ischemia and necrosis. • Turn with care (e.g., avoid shearing) to prevent injury to fragile skin. • Keep bed linen clean, dry, and wrinkle free to protect skin. • Use devices on bed (e.g., sheepskin) that protect the patient to reduce pressure to bony prominences by distributing body weight evenly. Nutrition Therapy • Complete a nutritional assessment to determine current nutritional status and needs. • Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements. • Determine need for enteral tube feedings to meet nutritional needs if patient is unable to ingest foods and fluids. Exercise Therapy: Joint Mobility • Perform passive or assisted ROM exercises to maintain joint ROM and muscle strength.

Outcomes (NOC)

Interventions (NIC) and Rationales

Immobility Consequences: Physiologic

• Lung congestion _____

• Pneumonia _____

• Pressure sore(s) _____

• Nutritional status _____

• Joint movement _____

• Muscle tone _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Airway Management

• Position patient to maximize ventilation potential to prevent aspiration and tongue from blocking airway.

• Remove secretions by encouraging coughing or by suctioning to remove accumulated secretions, reduce risk of aspiration, and ensure patent airway.

• Perform chest physical therapy to mobilize secretions and prevent pulmonary congestion.

Pressure Ulcer Prevention

• Use an established risk assessment tool to monitor individual’s risk factors (e.g., Braden scale [see eTable 12-3 on website]).

• Inspect skin over bony prominences and other pressure points at least daily when repositioning to identify potential or actual skin problems and initiate a plan of care.

• Turn every 1-2 hr as appropriate as prolonged pressure decreases circulation and leads to tissue ischemia and necrosis.

• Turn with care (e.g., avoid shearing) to prevent injury to fragile skin.

• Keep bed linen clean, dry, and wrinkle free to protect skin.

• Use devices on bed (e.g., sheepskin) that protect the patient to reduce pressure to bony prominences by distributing body weight evenly.

Nutrition Therapy

• Complete a nutritional assessment to determine current nutritional status and needs.

• Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements.

• Determine need for enteral tube feedings to meet nutritional needs if patient is unable to ingest foods and fluids.

Exercise Therapy: Joint Mobility

• Perform passive or assisted ROM exercises to maintain joint ROM and muscle strength.

ICP, Intracranial pressure; PaCO₂, partial pressure of carbon dioxide in arterial blood; PaO₂, partial pressure of oxygen in arterial blood; ROM, range of motion; SaO₂, oxygen saturation of arterial blood.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 57-2 Patient With Bacterial Meningitis

Nursing Diagnosis *

Decreased intracranial adaptive capacity†

Risk for ineffective cerebral tissue perfusion†

Nursing Diagnosis

Acute confusion related to impaired cerebral function as evidenced by inaccurate interpretation of environment, fluctuation in cognition and level of consciousness, and misperceptions

Patient Goals

1. Demonstrates appropriate cognitive function

2. Is oriented to person, place, and time

Outcomes (NOC)	Interventions (NIC) and Rationales
Acute Confusion Level • Disorientation of time, place, and person _____ • Impaired cognition _____ • Difficulty following complex commands _____ • Difficulty interpreting environmental stimuli _____ • Misinterpretation of cues _____ • Altered level of consciousness _____ Neurologic Status: Consciousness • Seizure activity _____ • Stupor _____ • Trance state _____ • Delirium _____ • Coma _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Neurologic Monitoring • Monitor level of consciousness to identify changes. • Monitor level of orientation. • Monitor vital signs because changes in cranial pressure are reflected in vital signs. • Note complaints of headache because this is a symptom of increased intracranial pressure. • Monitor response to stimuli: verbal, tactile, and noxious as indicators of cranial pressure. • Identify emerging patterns in data to anticipate changes in treatment. • Notify physician of change in patient condition so that changes in therapy may be made as necessary. Delirium Management • Monitor neurologic status on an ongoing basis to determine extent of problem. • Administer PRN (as needed) medications for anxiety or agitation to reduce fear and anxiety. • Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation. • Approach patient slowly and from the front to avoid stimulating or frightening patient. • Provide appropriate level of supervision/surveillance to monitor patient and to allow for therapeutic actions. • Reorient the patient to the health care provider with each contact to assist with orientation and reduce anxiety. • Communicate with simple, direct, descriptive statements to avoid overstimulation. • Assist with needs related to nutrition, elimination, hydration, and personal hygiene because the patient may lose awareness of the needs.

Outcomes (NOC)

Interventions (NIC) and Rationales

Acute Confusion Level

• Disorientation of time, place, and person _____

• Impaired cognition _____

• Difficulty following complex commands _____

• Difficulty interpreting environmental stimuli _____

• Misinterpretation of cues _____

• Altered level of consciousness _____

Neurologic Status: Consciousness

• Seizure activity _____

Neurologic Monitoring

• Monitor level of consciousness to identify changes.

• Monitor level of orientation.

• Monitor vital signs because changes in cranial pressure are reflected in vital signs.

• Note complaints of headache because this is a symptom of increased intracranial pressure.

• Monitor response to stimuli: verbal, tactile, and noxious as indicators of cranial pressure.

• Identify emerging patterns in data to anticipate changes in treatment.

• Notify physician of change in patient condition so that changes in therapy may be made as necessary.

Delirium Management

• Monitor neurologic status on an ongoing basis to determine extent of problem.

• Administer PRN (as needed) medications for anxiety or agitation to reduce fear and anxiety.

• Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation.

• Approach patient slowly and from the front to avoid stimulating or frightening patient.

• Provide appropriate level of supervision/surveillance to monitor patient and to allow for therapeutic actions.

• Reorient the patient to the health care provider with each contact to assist with orientation and reduce anxiety.

• Communicate with simple, direct, descriptive statements to avoid overstimulation.

• Assist with needs related to nutrition, elimination, hydration, and personal hygiene because the patient may lose awareness of the needs.

Nursing Diagnosis

Hyperthermia related to infection and abnormal temperature regulation by hypothalamus secondary to increased intracranial pressure as evidenced by increased body temperature

Patient Goal

Maintains body temperature within normal range

Outcomes (NOC)	Interventions (NIC) and Rationales
Thermoregulation • Hyperthermia _____ • Headache _____ • Increased skin temperature _____ • Drowsiness _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Fever Treatment • Monitor temperature as frequently as is appropriate. • Monitor blood pressure, pulse, and respirations to evaluate effects of hyperthermia. • Monitor intake and output because increased body temperature increases the risk of fluid deficit. • Monitor for decreased levels of consciousness because fever increases brain metabolism. • Encourage increased intake of oral fluids, as appropriate, to replace fluids lost through increased metabolism and diaphoresis. • Monitor for seizure activity that could reflect hyperthermia and increasing brain irritability. • Monitor temperature closely to prevent treatment-induced hypothermia.

Outcomes (NOC)

Interventions (NIC) and Rationales

Thermoregulation

• Hyperthermia _____

• Headache _____

• Increased skin temperature _____

• Monitor temperature as frequently as is appropriate.

• Monitor blood pressure, pulse, and respirations to evaluate effects of hyperthermia.

• Monitor intake and output because increased body temperature increases the risk of fluid deficit.

• Monitor for decreased levels of consciousness because fever increases brain metabolism.

• Encourage increased intake of oral fluids, as appropriate, to replace fluids lost through increased metabolism and diaphoresis.

• Monitor for seizure activity that could reflect hyperthermia and increasing brain irritability.

• Monitor temperature closely to prevent treatment-induced hypothermia.

Nursing Diagnosis

Acute pain related to headache and muscle aches as evidenced by general discomfort of head, joints, and muscles; apathy; grimacing on movements

Patient Goals

1. Reports satisfaction with pain control

2. Demonstrates no effects of pain

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Level • Reported pain _____ • Facial expressions of pain _____ • Muscle tension _____ • Restlessness _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Pain Management • Provide patient optimal pain relief with prescribed analgesics to relieve pain. • Select and implement a variety of measures (e.g., pharmacologic, nonpharmacologic, interpersonal) to facilitate pain relief (e.g., massage, range of motion) to promote comfort and show a caring attitude and to reduce joint stiffness and promote circulation. • Reduce or eliminate factors that precipitate or increase the pain experience (e.g., fever, fear). • Control environmental factors that may influence the patient’s response to discomfort (e.g., room temperature, lighting, noise) because pain can be exhausting to the patient. • Institute and modify pain control measures based on the patient’s response.
Collaborative Problem

Potential Complication

Seizure activity related to cerebral irritation

Nursing Goals	Nursing Interventions and Rationales
• Monitor for seizure activity • Carry out appropriate medical and nursing interventions • Report and record any seizure activity	• Monitor for seizure activity so that interventions can be initiated immediately. • Keep side rails up and padded to protect patient if a seizure occurs. • Administer sedative and antiseizure drugs as ordered to control or prevent seizure activity. • Perform interventions to treat underlying causes of inflammatory brain condition to prevent seizure activity.

ICP, Intracranial pressure; PRN, as needed.

^*Nursing diagnoses listed in order of priority.

^†Because cerebral edema and increased intracranial pressure may occur with bacterial meningitis, see the related nursing care plan, eNCP 57-1, for these nursing diagnoses.

Primary versus secondary injury is another important concept in understanding ICP. Primary injury occurs at the initial time of an injury (e.g., impact of car accident, blunt-force trauma) that results in displacement, bruising, or damage of the three components. Secondary injury is the resulting hypoxia, ischemia, hypotension, edema, or increased ICP that follows the primary injury. Secondary injury, which could occur several hours to days after the initial injury, is a primary concern when managing brain injury. Nursing management of the patient with an acute intracranial problem must include management of secondary injury, and thus increased ICP.

Regulation and Maintenance of Intracranial Pressure

The cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain. CPP is equal to the MAP minus the ICP (CPP = MAP − ICP) (see example in Table 57-1). This formula is clinically useful, although it does not consider the effect of cerebrovascular resistance. Cerebrovascular resistance, generated by the arterioles within the cranium, links CPP and blood flow as follows: CPP = Flow × Resistance.

TABLE 57-1

CALCULATION OF CEREBRAL PERFUSION PRESSURE

CPP = MAP − ICP

Compliance=Volume/Pressure

Example: Systemic blood pressure = 122/84 mm Hg

MAP = 97 mm Hg

ICP = 12 mm Hg

CPP = 85 mm Hg

CPP, Cerebral perfusion pressure; DBP, diastolic blood pressure; ICP, intracranial pressure; MAP, mean arterial pressure; SBP, systolic blood pressure.

When cerebrovascular resistance is high, blood flow to brain tissue is impaired. Transcranial Doppler is a noninvasive technique used in intensive care units (ICUs) to monitor changes in cerebrovascular resistance.

As the CPP decreases, autoregulation fails and CBF decreases. Normal CPP is 60 to 100 mm Hg. A CPP of less than 50 mm Hg is associated with ischemia and neuronal death. A CPP of less than 30 mm Hg results in ischemia and is incompatible with life.

Normally, autoregulation maintains an adequate CBF and perfusion pressure primarily by adjusting the diameter of cerebral blood vessels and metabolic factors that affect ICP. It is critical to maintain MAP when ICP is elevated.

Remember that CPP may not reflect perfusion pressure in all parts of the brain. There may be local areas of swelling and compression limiting regional perfusion pressure. Thus a higher CPP may be needed for these patients to prevent localized tissue damage. For example, a patient with an acute stroke may require a higher BP, increasing MAP and CPP, in order to increase perfusion to the brain and prevent further tissue damage.

The relationship of pressure to volume is depicted in the pressure-volume curve (Fig. 57-2). The curve is affected by the brain’s compliance. Compliance is the expandability of the brain. It is represented as the volume increase for each unit increase in pressure. With low compliance, small changes in volume result in greater increases in pressure.