About
A buildup of fluid within the skull compartment causing pressure, herniation, or ischemia of brain tissue.
Assess
Seizures, non-responsiveness, nausea, vomiting, hypertension, bradycardia, changes in neuro status
Complications
Death, coma, neurological changes, pneumonia, contractures
Diagnosis
- Risk for injury related to tissue death.
- Impaired cerebral tissue perfusion related to excess fluid compression.
Goals
- The client will remain free from injury.
- The client will have adequate tissue perfusion of brain tissue.
- The client will have decreasing intracranial pressure as evidenced by ICP monitoring.
- The client will remain free from complications due to immobility.
- the client will have an increasing Glasgow coma scale score ( 15 point scale with 15 being optimal/ normal).
Interventions
- Priority is monitoring for airway, breathing and circulation.
- Perform neuro check every hour minimally after acute head trauma.
- Monitor for s/s of increasing intracranial pressure ( seizures, non-responsiveness, nausea, vomiting, hypertension, bradycardia, changes in neuro status).
- Have endotracheal equipment at the bedside in case of respiratory emergency.
- Monitor pain level, respiratory status, neuro status, electrolytes, fluid volume status, intakes/ outputs, vital signs, and pulse oximetry frequently.
- May need to be in an induced coma to prevent stress, agitation, pain, etc.
- Administer medications ( Mannitol, glucocorticoids, etc.) as indicated.
- Encourage coughing and deep breathing techniques or suction ( with extreme care to prevent increase in ICP) as needed.
- Maintain head of bed at 30 degrees.
- Initiate supportive care for bed-bound patient.
- Initiate plans for continued rehabilitation, physical therapy, occupational therapy, etc as indicated.
- Monitor for signs/ symptoms of complications.
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