Nursing interventions can positively or negatively affect intracranial pressure (ICP). Nurses have a unique opportunity to manage patient care in order to decrease elevated ICP and prevent secondary brain injury. However, patients also must be diligently monitored for secondary effects such as ventilator-associated pneumonia (VAP) and skin breakdown. It becomes a delicate balance to maintain brain function while helping to prevent other secondary injury.
Understand the effect of nursing care on intracranial pressure.
Determine ICP reference ranges for each patient as determined by physician orders, underlying pathology, and plan of care.
Monitor pulmonary hygiene and the effects of interventions, such as suctioning and patient positioning, on intracranial pressure.
Determine a daily interdisciplinary plan of care including individualized daily goals.
Initiate nursing consults for skin management and hygiene as indicated by the patient’s condition.
Plan nursing care at intervals to allow patients with elevated...