13. Increased intracranial pressure (ICP): intracranial hypertension associated with altered states of consciousness.
1. Pathophysiology: increases in intracranial blood volume, cerebrospinal fluid, or brain tissue mass-increased intracranial pressure-impaired neural impulse transmission cellular anoxia, atrophy.
2. Risk factors:
1. Congenital anomalies (hydrocephalus).
2. Space-occupying lesions (abscesses or tumors).
3. Trauma (hematomas or skull fractures).
4. Circulatory problems (aneurysms, emboli).
5. Inflammation (meningitis, encephalitis).
3. Assessment:
1. Subjective data:
1. Headache (early, but nonspecific symptom).
2. Nausea.
3. Visual disturbance (diplopia).
2. Objective data:
1. Changes in level of consciousness (early sign).
2. Pupillary changes-unequal, dilated, and unresponsive to light (late sign).
3. Vital signs-changes are variable.
1. Blood pressure-gradual or rapid elevation, widened pulse pressure.
2. Pulse-bradycardia, tachycardia; significant sign is slowing of pulse as blood pressure rises.
3. Respirations-pattern changes(Cheyne-Stokes, apneusis, Biot’s), deep and sonorous; hiccups.
4. Temperature-moderate elevation.
4. Projectile vomiting (more common in children).
5. Diagnostic test: Head CT-structural changes.
4. Analysis/nursing diagnosis:
1. Altered cerebral tissue perfusion related to increased intracranial pressure.
2. Altered thought processes related to cerebral anoxia.
3. Ineffective breathing pattern related to compression of respiratory center.
4. Risk for aspiration related to unconsciousness.
5. Self-care deficit related to altered level of consciousness.
6. Impaired physical mobility related to abnormal motor responses.
5. Nursing care plan/implementation:promote adequate oxygenation and limit further impairment.
1. Vital signs: report changes immediately.
2. Patent airway; keep alkalotic, to prevent increased intracranial pressure from elevated CO₂; hyperventilate if necessary.
3. Give medications as ordered:
1. Hyperosmolar diuretics (mannitol, urea) to reduce brain swelling.
2. Steroids (dexamethasone [Decadron]) for anti-inflammatory action.
3. Antacids or H₂ antagonist to prevent stress ulcer.
4. B Position: head of bed elevated 30 degrees.
5. Fluids: restrict; strict I&O.
6. Cooling measures to reduce temperature, because fever increases ICP.
7. Prepare for surgical intervention.
6. Evaluation/outcome criteria:
1. No irreversible brain damage-regains consciousness.
2. Resumes self-care activities.


14. Craniotomy: excision of a part of the skull (burr hole to several centimeters) for exploratory purpose and biopsy; to remove neoplasms, evacuate hematomas or excess fluid, control hemorrhage, repair skull fractures, remove scar tissue, repair or excise aneurysms, and drain abscesses; produces minimal neurological deficit.
1. Analysis/nursing diagnosis:
1. Altered cerebral tissue perfusion related to edema.
2. Altered thought processes related to disorientation.
3. Self-care deficit related to continued neurological impairment.
2. Nursing care plan/implementation:
1. Preoperative:
1. Goal: obtain baseline measures.
1. Vital signs.
2. Level of consciousness.
3. Mental, emotional status.
4. Pupillary reactions.
5. Motor strength and functioning.
2. Goal: provide psychological support: listen; give accurate, brief explanations.
3. Goal: prepare for surgery.
1. Cut hair; shave scalp (usually done in surgery); save hair if patient/family desire.
2. Cover scalp with clean towel.
3. Insert indwelling Foley catheter as ordered.
2. Postoperative:
1. Goal: prevent complications and limit further impairment.
1. Vital signs (indications of complications):
1. Decreased blood pressure-shock.
2. Widened pulse pressure-increased ICP.
3. Respiratory failure-compression of medullary respiratory centers.
4. Hyperthermia-disturbance of heat-regulating mechanism; infection.
2. Neurological:
1. Pupils-ipsilateral dilation (increased ICP), visual disturbances.
2. Altered level of consciousness.
3. Altered cognitive or emotional status-disorientation common.
4. Motor function and strength- hypertonia, hypotonia, seizures.
3. Blood gases, to monitor adequacy of ventilation.
4. Dressings: check frequently; aseptic technique; reinforce as necessary.
5. Observe for:
1. CSF leakage (glucose-positive drainage from nose, mouth, ears)-report immediately.
2. Periorbital edema-apply light ice compresses as necessary remove crusts from eyelids.
6. Check integrity of seventh cranial nerve (facial)-incomplete closure of eyelids.
7. Position:
1. Supratentorial surgery (cerebrum)-semi-Fowler’s (30-degree elevation); may not lie on operative side.
2. Infratentorial (brain stem, cerebellum)-flat in bed (prone); may turn to either side but not onto back.
8. Fluids: NPO until bowel sounds return, alert, and intact gag, swallow, and cough reflexes present.
9. Medications as ordered:
1. Osmotic diuretics (mannitol).
2. Corticosteroids (dexamethasone [Decadron]).
3. Mild analgesics (do not mask neurological or respiratory depression).
4. Stool softeners to prevent constipation and straining.
10. Orient frequently to person, time, place-to reduce restlessness, confusion.
11. Side rails up for safety.
12. Avoid restraints (may increase agitation and ICP).
13. Ice bags to head to reduce headache.
14. Activity: assist with ambulation.
2. Goal: provide optimal supportive care.
1. Cover scalp once dressings are removed (scarves, wigs).
2. Deal realistically with neurological deficits-facilitate acceptance, adjustment, independence.
3. Goal: health teaching.
1. Prepare for physical, occupational, or speech therapy, as needed.
2. Activities of daily living.
3. Evaluation/outcome criteria:
1. Regains consciousness-is alert, oriented.
2. Resumes self-care activities within limits of neurological deficits.