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Definition of the Medical Diagnosis

After a head injury, some fatal cases has the central nervous system affected and signs of increased intracranial pressure that involve a rise in the pressure inside the skull that can either cause or occur due to brain injury (Maiese, 2019). The cranial pressure occurs due to three essential segments in the brain comprising of intracranial blood volume, cerebrospinal fluid (CSF) and central nervous system tissue. Normally, the intracranial pressure rangers from 5-15 mmHg, which is lower than the mean pressure in the systemic arterial, but is much more than the pressure in venous (Thompson, 2012).

Signs and symptoms

· The general symptom for an increase in intracranial pressure includes vomiting without nausea, headache, altered level of consciousness, ocular palsies, back pain, and in some cases papilledema. In cases where papilledema is present, the patient might also experience optic atrophy, visual disturbances and eventually blindness.

· When the patient suffers brain tissue displacement, additional signs like pupillary dilatation, Cushing’s triad and abducens palsies may be present. The Cushing's triad occurs due to an increase in the systolic pressure, bradycardia, widened pulse pressure and abnormal respiratory pattern. High intracranial pressure could be checked through low heart rate in children.

· The patient must experience irregular respiratory rate due to intracranial pressure increase due to damage of the brain interface with the respiratory drive. The patient must experience Cheyne–Stokes respiration where the breathing rate is high followed by absent period due to cerebral hemispheres damage. In other cases where the patient has the tegmentum or brain stem is damaged, the patient must experience Hyperventilation.

· Patients who have normal blood pressure are also likely to retain an intracranial pressure of 25-40 mmHg unless the situation where there is a shift of tissues simultaneously. However, when the intracranial pressure ranges between 40 and 50 mmHg, then there is a need to evaluate the cerebral perfusion that led to a decline in the level of consciousness. Any further increase in the intracranial pressure could result in brain death or even infarction.

· In young children and infants, intracranial pressure increase effects vary due to the cranial sutures are not closed.

Potential Complications

There are numerous complications that could arise if the condition of the patient did not get the intervention on time. Some of the main complications that have the potential of occurrence include:

· Death

· Permanent neurological problems

· Reversible neurological problems

· Seizures

· Stroke

Head to Toe Assessment

General: The patient suffers general weaknesses in the body that result in the inability to walk or talk, change of behaviour, and lack of energy or sleepiness.

Vital signs: weight loss of 1.82 kg over a 24-hour period, decreased skin turgor, and dry mucous membranes. Urine output for the same 24-hour period is 3.5 L/m2.

Head: severe headache, Central Nervous System effect leads to confusion and blurred vision

Heart: there is increased heart rate, shallow breathing or reduced respiratory rate, and high blood pressure both systolic and diastolic.

Gastrointestinal tract: The patient could experience vomiting without necessarily experiencing nausea

Legs: Weakness resulting due to head injury leading to problems with moving or walking and inability to talk

Diagnostic and Lab Studies Expected Outcomes

The most important diagnostic tool is the Glasgow Coma Scale (GCS) that is a useful test for identifying the degree of impairments of a patient admitted for increased intracranial pressure increase that takes a patient into a state of unconsciousness. The second type of diagnostic tool valuable in the patient is the CBC that indicates the haemoglobin for blood loss due to the accident and injury. Cranial X-ray is needed to assess the possibility of injury to the chest due to the accident. The other type of diagnostic assessment is the CT scan or the MRI for the brain to evaluate the extent of damage and the presence of oedema and haemorrhage in the brain due to the injury. Serum electrolytes (sodium, potassium imbalance) can be used in evaluating whether there is any risk of acid-base imbalance due to the accidents (Smith & Amin-Hanjani, 2019). The renal profile is needed to the low voiding indicated from the examination.

All NANDA Nursing Diagnosis

The problem facing the patient is a potential increase in the intracranial pressure that has resulted in the patient to go into a coma or become unconscious. This requires immediate attention to ensure that the patient condition stabilizes. The nursing interventions aimed at stabilizing the condition of the patient.

(a) Ineffective Tissue Perfusion

The (cerebral) related to increased ICP as evidenced by decreased LOC, sluggish pupil response, papilledema, and posturing

· Desired Outcomes

ICP will be between 1 and 15 mm Hg, and the GCS will be 9 or greater.

(b) Risk of infection for impaired skin

· Due to the accident, the patient may suffer rashes and bruises that could be a pathway for infection resulting in severe pain in the affected areas. This requires intervention measures to prevent infections.

· Desired Outcomes

The client is free from an infection that could impair the skin integrity that results in overall proper skin integrity and recovery free of infections.

· Interventions and Rationale

(c) Emotional and Psychological Distress

· After recovering from the coma or unconsciousness, the patient may experience anxiety regarding the condition and potential trauma caused by the accident and subsequent injuries. The nurse will require to offer emotional or psychological support.

· Desired Outcome

The patient indicating effective acceptance of the state and development of positive attitudes towards the recovery process as part of the healing.

· Intervention and Rationale

Evaluation

The patient recovers from the comma and begin learning the environment. This is a pathway to recovery.

References

Hussein, M., Zettel, S., Suykens, A. (2017).The ABCs of managing increased intracranial pressure. Journal of Nursing Education and Practice, 7(4), 6-14.

Levine, W., Allain, R., Alston, T., Dunn, P., Kwo, J., Rosow, C. (2010). Anesthesia for neurosurgery. In SA LeGrand & M Szabo (8th ed), Clinical anesthesia procedures of the Massachusetts General Hospital: 389-408.