Mindanao Sanitarium and Hospital College

Department of Nursing

NURSING CARE PLAN (NCP)

Name: Baby Hydro Age: 39 days old Gender: Male
Chief Complaints: Room No:
Problem Identified: Hydrocephalus
Nursing Diagnosis: Decreased Intracranial Adaptive Capacity r/t Space- Occupying Lesion.
Cause Analysis: ( With Ref.) Intracranial pressure, (ICP), is the pressure exerted by the cranium on the brain tissue, cerebrospinal fluid (CSF), and the brain's circulating blood volume. ICP is a dynamic phenomenon
constantly fluctuating in response to activities such as exercise, coughing, straining, arterial pulsation, and respiratory cycle. An increase in pressure, most commonly due to head injury leading to intracranial
hematoma or cerebral edema can crush brain tissue, shift brain structures, contribute to hydrocephalus, cause the brain to herniate, and restrict blood supply to the brain, leading to an ischemic cascade. If left
untreated the patient may result to coma or worst death. (Medical Surgical Nursing by Ignatavicius)

Cues Objectives Nursing Intervention Rationale Evaluation

SUJECTIVE: SHORT TERM: INDEPENDENT: The SO shall have understand the

- inceased head circumference
(37cm) After 1-2° of NI the SO will be able to
- abnormal reflexes (no rooting, understand the client’s condition and be
and moro reflexes) able perform actively in promoting the
clients condition having now a higher
- a bulging forehead with level of understanding of the client’s
prominent fontanel, a slowed condition and complications that may
heartbeat occur.
- respiratory rate
LONG TERM;
- a thin transparent scalp.
After 6-7 days of NI the client will be able
to demonstrate stable ICP, normalization
of pressure waveforms/response to
stimuli.
To gain the client and SO’s trust. client’s condition and be able perform
>Establish rapport
actively in promoting the clients condition
>To obtain data for comparison. having now a higher level of
>Monitor VS.
understanding of the client’s condition
>To alter care appropriately. and the complications that may occur.
>Monitor/document changes in ICP
waveform and responses to stimuli.
>Assess eye opening and The client shall have demonstrated
> To note degree of impairment
position/movement, Pupils (size, stable ICP and normalization of pressure
equality, light reactivity), purposeful and
non-purposeful motor response waveforms/response to stimuli.
comparing left and right sides, presence
of reflexes, nuchal rigidity,
consciousness and mental state. >To increase SO’s understanding of the
client’s condition and will be able to
>Provide information about the client’s decide properly for the client’s care.
condition including the complications
which may arise once untreated

>Elevate HOB and maintain head/neck >To promote circulation/venous drainage

in midline/neutral position
>To reduce CNS stimulation and
>Decrease extraneous stimuli/provide promote relaxation.
comfort measures
>To decrease factors which may
>Limit activities that increases contribute in further increasing ICP.
intrathoracic/abdominal pressure
 COLABORATIVE:
>Administer medications as
ordered (e.g. antihypertensives, >To pharmacologically manage
diuretics, analgesics, antipyretics, client’s condition and maintain
vasopressors, antiseizure, homeostasis
neuromuscular blocking agents,
and corticostreiods)

>Prepare pt. for surgery as

indicated (Space Occupying
>To reduce ICP and enhance
Lesion)
circulation
>Refer accordingly
>To have a continuous client’s
care

References: Nursngg Care Plan by Marilyn Doenge