{ "name": "Traumatic Brain Injury & Increased ICP", "slug": "traumatic-brain-injury", "url": "https://nursingplex.com/care-plans/traumatic-brain-injury", "category": "Neurological", "summary": "Head injury care with ICP control, neuro checks and stimulation limits.", "nursing_diagnoses": [ "Ineffective cerebral tissue perfusion", "Risk for injury", "Impaired gas exchange" ], "overview": [ "Traumatic brain injury (TBI) is damage to the brain from an external force — a fall, motor vehicle crash, assault or blast. The primary injury happens at the moment of impact and cannot be reversed. Everything nursing does is aimed at the secondary injury: the hypoxia, hypotension, edema, hemorrhage and rising intracranial pressure that continue to kill neurons in the hours and days afterward.", "The skull is a fixed box holding brain tissue, blood and cerebrospinal fluid. The Monro–Kellie principle states that an increase in any one component must be offset by a decrease in another or pressure rises. Once compensation is exhausted, small volume changes produce steep pressure increases, cerebral perfusion falls, and herniation becomes possible.", "Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure. That single relationship explains most of the care: keep ICP down and mean arterial pressure adequate. Normal ICP is roughly 5–15 mmHg and the usual perfusion target is above 60 mmHg." ], "key_facts": [ { "label": "Earliest ICP sign", "text": "A change in level of consciousness — restlessness, confusion or difficulty rousing — before any vital sign change." }, { "label": "Cushing's triad", "text": "Rising systolic pressure with widening pulse pressure, bradycardia and irregular respirations — a late, ominous sign of impending herniation." }, { "label": "Perfusion math", "text": "CPP = MAP − ICP; keep CPP above about 60 mmHg." }, { "label": "Positioning", "text": "Head of bed elevated 30 degrees with the head midline and neutral; avoid neck flexion or tight collar ties that obstruct venous drainage." }, { "label": "Never do", "text": "Do not suction nasally or insert a nasogastric tube with suspected basilar skull fracture; use the oral route." } ], "nursing_priorities": [ "Maintain airway, oxygenation and normal carbon dioxide levels — hypoxia and hypercapnia both raise ICP.", "Detect neurologic deterioration early through serial focused assessment.", "Prevent and treat rising intracranial pressure.", "Maintain cerebral perfusion pressure by avoiding hypotension.", "Protect the patient from injury, seizures and aspiration.", "Prevent infection, especially with CSF leak or invasive monitoring.", "Support nutrition and skin integrity during a prolonged, hypermetabolic course.", "Prepare family for cognitive, behavioral and emotional changes during recovery." ], "assessment": { "subjective": [ "Headache, described as worsening or unrelieved", "Nausea, dizziness, blurred or double vision", "Confusion, trouble concentrating, memory gaps around the event", "Sensitivity to light or sound, irritability, emotional lability", "Family reporting 'this is not how they normally act'" ], "objective": [ "Decreasing level of consciousness and falling Glasgow Coma Scale score", "Pupil changes: sluggish, unequal, or a fixed dilated pupil suggesting herniation", "Projectile vomiting without nausea", "Motor deterioration: focal weakness, then abnormal posturing (decorticate progressing to decerebrate)", "Cushing's triad in late deterioration; irregular respiratory patterns", "Clear or blood-tinged drainage from nose or ear, periorbital or mastoid bruising (basilar skull fracture)", "Seizure activity; restlessness that is disproportionate to stimuli", "Rising ICP readings and falling calculated cerebral perfusion pressure" ], "related_factors": [ "Cerebral edema and hematoma formation increasing intracranial volume", "Impaired cerebral autoregulation after injury", "Hypoxia, hypercapnia and hypotension amplifying secondary injury", "Obstructed venous outflow from head position, neck flexion or Valsalva", "Fever, pain, agitation and clustered stimulation increasing cerebral metabolic demand", "Loss of protective reflexes and immobility" ] }, "goals": [ "The client will maintain ICP within the ordered range and cerebral perfusion pressure above 60 mmHg.", "The client will maintain or improve level of consciousness with a stable or rising Glasgow Coma Scale score.", "The client will maintain a patent airway with SpO2 and end-tidal CO2 within ordered parameters.", "The client will remain free of seizures, aspiration, infection and pressure injury.", "The client will maintain adequate nutrition and stable weight during recovery.", "The family will describe expected cognitive and behavioral changes and available rehabilitation resources." ], "interventions": [ { "title": "1. Neurologic surveillance", "points": [ "Perform serial neurologic checks at the ordered interval using the same scale each time so that trends, not snapshots, guide decisions.", "Report any decline in level of consciousness immediately — it precedes vital sign changes by hours.", "Check pupil size, equality and reaction with every assessment; a newly enlarging unreactive pupil is an emergency.", "Assess motor strength bilaterally and note any new asymmetry or posturing.", "Do not delay reporting because a change is 'small'; early treatment of rising ICP is what prevents herniation." ] }, { "title": "2. Controlling intracranial pressure", "points": [ "Keep the head of the bed at about 30 degrees with the head midline and neutral; hip flexion beyond 90 degrees and neck rotation both impede venous drainage.", "Space out activities and avoid clustering suctioning, turning and bathing, because ICP rises additively with stimulation.", "Preoxygenate before suctioning, limit each pass to about 10 seconds and no more than two passes, and never suction nasally with suspected basilar fracture.", "Prevent Valsalva: treat constipation with stool softeners, avoid straining, and teach the alert patient to exhale during repositioning.", "Maintain a calm, quiet environment with dim light and limited noise; encourage familiar voices, which are usually calming rather than stimulating.", "Treat fever aggressively — every degree of temperature elevation increases cerebral metabolic demand.", "Give osmotic therapy such as mannitol or hypertonic saline as ordered, monitoring serum osmolality, sodium and urine output closely.", "Maintain ordered CO2 targets; routine aggressive hyperventilation is avoided because it causes vasoconstriction and ischemia." ] }, { "title": "3. Airway, oxygenation and ventilation", "points": [ "Maintain a patent airway; intubate for a Glasgow Coma Scale of 8 or less or a lost gag reflex.", "Keep oxygen saturation and arterial values within ordered ranges — hypoxia is one of the strongest predictors of poor outcome.", "Auscultate for aspiration; keep the head elevated and use oral care with suction to reduce ventilator-associated pneumonia.", "Monitor end-tidal CO2 continuously when ventilated." ] }, { "title": "4. Hemodynamic and fluid management", "points": [ "Avoid even brief episodes of hypotension; a single systolic drop below 90 mmHg measurably worsens outcome.", "Maintain euvolemia with isotonic fluids; hypotonic solutions such as D5W worsen cerebral edema and are avoided.", "Monitor serum sodium and osmolality for diabetes insipidus (dilute high-volume urine, rising sodium) and SIADH (concentrated urine, falling sodium) — both are common after TBI.", "Record strict intake and output, hourly urine output and daily weights." ] }, { "title": "5. Safety, seizures and sensory protection", "points": [ "Keep the bed low with side rails up, pad rails when seizures are a risk, and have suction and oxygen at the bedside.", "Give prophylactic anticonvulsants as ordered in the early post-injury period and monitor levels and sedation.", "Document seizure onset, type, duration and post-ictal state precisely.", "Protect eyes with lubricant or shields if the blink reflex is absent.", "Reorient frequently and use familiar objects, clocks and calendars for the recovering patient." ] }, { "title": "6. Infection prevention with CSF leak or monitoring devices", "points": [ "Test suspicious nasal or ear drainage for a halo sign or glucose as directed; never pack the nose or ear.", "Instruct the patient not to blow the nose, sneeze forcefully or strain.", "Keep external ventricular drain systems level at the ordered reference point, clamp during position changes as per protocol, and use strict sterile technique at the insertion site.", "Monitor for fever, nuchal rigidity and worsening headache as signs of meningitis." ] }, { "title": "7. Nutrition, mobility and skin", "points": [ "Begin feeding early once the gut is functional; TBI produces a markedly hypermetabolic, catabolic state.", "Use the oral rather than nasal route for gastric tubes when a basilar fracture is suspected.", "Reposition on a schedule with attention to keeping the head neutral, and use pressure-redistribution surfaces.", "Provide passive range of motion, splinting and early therapy consultation to prevent contracture and foot drop.", "Apply VTE prophylaxis as ordered; immobility plus trauma is a high-risk combination." ] }, { "title": "8. Family support and cognitive rehabilitation", "points": [ "Prepare the family for personality change, impulsivity, poor judgment, emotional outbursts and fatigue — these distress families more than physical deficits.", "Teach a structured, low-stimulation routine and simple one-step directions during recovery.", "Involve rehabilitation, speech-language pathology and neuropsychology early.", "Encourage the family to keep a journal of progress; recovery is measured in months, not days." ] } ], "patient_teaching": [ "Report worsening headache, repeated vomiting, increasing sleepiness, one-sided weakness, slurred speech or a seizure immediately.", "Avoid alcohol, sedatives and any new medication without approval during recovery.", "Return to work, driving and sport only when specifically cleared; a second head injury before recovery is far more dangerous.", "Expect fatigue, difficulty concentrating and irritability, and plan rest periods and short task blocks.", "Use written lists, alarms and a fixed daily routine to compensate for memory problems.", "Continue prescribed anticonvulsants for the full course and do not stop them independently.", "Attend all rehabilitation appointments and connect with brain injury support groups.", "Prevent recurrence: seat belts, helmets, fall-proofing the home and treating vision or balance problems." ] }