Decreased Intracranial Adaptive Capacity Care Plan is required when a person has problems with intracranial fluid dynamic mechanisms. Normally, they compensate for the escalation of intracranial volumes. Still, in cases of improper functioning, the mechanisms lead to occurring disproportionate boosts of ICP (intracranial pressure) as a response to multiple stimuli that can be either non-noxious or noxious.
Defining Characteristics of a Decreased Intracranial Adaptive Capacity Care Plan
- Basic ICP is 10 mm Hg;
- Sudden boost in ICP proceeding unique nursing intervention;
- Raised P2 ICP form of the wave;
- Occurring escalation of 10 mm Hg for more than five minutes of proceeding outside impetus.
Adjacent Factors:
- Brain damage;
- Maintained heightened ICP;
- Sustained low blood pressure with decline of cerebral perfusion intracranial high blood pressure.
Focus of Evaluation:
- Beliefs/ values;
- Comfort;
- Eradication;
- Electrolytes and fluids;
- Pharmacologic functions;
- Neuro-cognition;
- Cardiac functioning;
- Respiratory functioning.
The Patient Is Expected to:
- Demonstrate no sign of fever;
- Demonstrate no evidence of neurological malfunctions;
- Maintain regular ABG levels;
- Maintain normal pattern of breathing;
- Preserve normal state of skin and its integrity;
- Show no signs of infection;
- Manage normal bowel function.
Nursing Care Plan
Decreased intracranial adaptive capacity meaning helps carry out the process of informational assessment to determine corresponding intervention process. Performance: if usable, there is a need to sustain ICP systems of monitoring. Moreover, careful consideration must be paid to make sure that the system is properly operating in order to arrange authentic data. Apply sterile technique for implementing changes in order to avert contagion of infection and equipment. Keep up a patent airway as well as suction merely in emergent cases. When using suction improperly or irrelevantly, it may lead to severe coughing and may as well provoke Valsalva maneuver, which, in its turn increases pressure in thorax and reduces cerebral venous drainage. Besides, it may lead to the cerebral blood amount increase, which subsequently elevates ICP.
A patient’s head should be maintained in neutral position and should thus be kept upright (the head of the bed should be heightened to 15 – 30 ). If there is no opportunity to maximize the angle of the bed head, it is recommended to use pillows, rolled towels, sandbags, etc.
When a patient needs to be repositioned or moved somewhere, it is a must to use a draw sheet in order to avoid atrophy. When taking care of the patient, one should ensure that he/ she uses minimum of stimuli. At the same time, a patient has to be repositioned or at least turned in order to prevent the risk of atelectasis. To keep muscles in tonus, it is important to help a patient perform ROM exercises.
Decreased Intracranial Adaptive Capacity Goals
- Provide adequate teaching to families and patients about the aspects of care that can be delivered at home. Besides, it is important to teach on emotional stability and participation in the health care without being anxious and nervous.
- A patient’s family members should be properly instructed on how to stroke the patient’s hands, face or arms in a gentle way without causing pain and irritation. Family members are encouraged to participate in such treatment and be involved in the physical contact with the sick family member as it helps patients to reduce stress levels.
Nursing care should be delivered in a comfortable and calm manner. Family members should be also alarmed against discussing some upsetting issues with the patient. Discussion of some unpleasant topics that may make one nervous is deteriorating for emotional stability and psychological health. Besides, it may also lead to the increase in ICP. Patients should be encouraged to express their inner feelings and emotions concerning their diagnosis, options for interventions and healthcare treatment as well as recovery process.
To help family members cope with hard cases, they are encouraged to attend family conferences on proper health care at home. With the help of professional support and advice, family members will be able to cope with the case in a more timely and adequate manner. If patients are hard to deal with emotionally or if they are prone to depression, it is recommended to refer them to some kind of a support group.
In short, the following recommendations should be considered:
- It is crucial to take into account the proper functioning of the system when providing information on ways of treatment.
- A nurse should control the everyday process of taking care of patients to make sure that contamination and infection is avoided. Sterile techniques should be used.
- Suction and airway should be maintained in cases of emergency.
- A patient should be positioned appropriately.
- Soothing environment should be provided.
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