Critical care case study - Intracranial hypertension: Nursing

Nurse. Kenji works in the neurological intensive care unit and is caring for Felix.

A 22 year old patient who was admitted after experiencing a blow to the head while playing ice hockey. Nurse, Kenji goes to the steps of the clinical judgment measurement model to make clinical decisions about felix's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions taking action and evaluating outcomes.

First, nurse Kenji recognizes important cues like felix's vital signs which are temperature 100.1 °F or 37.8 °C, heart rate, 84 BPM respirations, 18 breaths per minute BP, 1 36/72 millimeters of mercury and oxygen saturation, 96% on 2 L of oxygen per nasal cannula.

He also has an intracranial pressure or ICP monitor in place that shows an ICP of 21 millimeters of mercury and his cardiac monitor shows normal sinus rhythm.

Nurse, Kenji then performs a focused neurological assessment and calculates a Glasgow coma scale or GCS score of 11 with both pupils equal and reactive to light.

Next. Nurse Kenji analyzes these cues.

He reviews the electronic health record or EHR and notes that Felix had a computed tomography or CT scan that ruled out a skull fracture and intracranial bleeding.

But showed cerebral edema. Nurse, Kenji knows the rigid skull contains fixed amounts of brain matter, cerebral spinal fluid or CSF and blood and any increase in volume of.

One of these components must be compensated by a decrease in one of the other components. For example, an increase in brain matter due to cerebral edema can be compensated by an adjustment to the volume of cerebral blood flow, increasing absorption of CSF or shifting CSF from the intracranial space into the spinal column.

However, in situations where these compensatory mechanisms fail. ICP can increase significantly if left untreated nurse, Kenji knows that a sustained increase in ICP above 20 millimeters of mercury called intracranial hypertension can compromise cerebral perfusion pressure or CPP leading to impaired delivery of oxygen, glucose and other nutrients to the brain.

Complications of intracranial hypertension include infarction and brain herniation. Nurse, Kenji realizes that Felix needs prompt treatment to lower his ICP.

Using the information he's gathered. Nurse Kenji chooses a priority hypothesis of altered cerebral perfusion.

Then he generates solutions to address felix's altered cerebral perfusion including pharmacologic and nonpharmacologic interventions.

He establishes the expected outcome that after intervening Felix's ICP will be less than 20 millimeters of mercury within an hour.

Then nurse Kenji takes action to implement these solutions. First.

He discusses his assessment findings with the healthcare provider who orders an IV infusion of 3% hypertonic saline and an antipyretic medication.

There are also orders for an as needed or P RN analgesic to promote comfort. After gathering supplies.

Nurse Kenji reenters Felix's room where his mother Angela is at the bedside. I just spoke with the health care provider and they've ordered some medications to help stabilize the pressure inside Felix's head.

I'll also give him some medications to help maintain a normal temperature and comfort. Angela tells nurse Kenji that she understands Felix's plan of care.

And nurse Kenji administers the IV fluids and medications following safe medication administration principles. Nurse Kenji then adjusts Felix's bed to a semi Fowler position to keep his head elevated, dims the lights to reduce stimulation and covers Felix in a light sheet to avoid overheating.

He sets the BP monitor to take readings every five minutes and reassures Felix and Angela that he'll be monitoring his ICP measurements closely.

10 minutes later, nurse Kenji reassesses Felix to evaluate the outcomes of his actions. He takes his vital signs which are temperature 100 °F or 37.7 °C, heart rate, 74 BPM, respirations, 16 breaths per minute BP, 1 28/72 millimeters of mercury and oxygen saturation, 96%.

And his ICP monitor shows a pressure of 20 millimeters of mercury. Nurse, Kenji continues to check Felix's ICP every five minutes and after 15 minutes, he notes Felix's ICP is 19 millimeters of mercury.

All right. As a quick recap, nurse Kenji recognized and analyzed cues related to felix's altered cerebral perfusion and prioritized hypotheses and generated solutions to address this problem.

Nurse Kenji then implemented pharmacologic and non pharmacologic measures to manage felix's altered cerebral perfusion and evaluated the outcomes compared to the expected outcomes.

Since Felix's ICP is now 19 millimeters of mercury. Nurse Kenji determined the plan of care was successful.