00049 Decreased intracranial adaptive capacity

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00049 Decreased intracranial adaptive capacity

Definition of the NANDA label

Compromise of the dynamics of the mechanisms that normally compensate for an increase in intracranial volume, resulting in repeated disproportionate increases in baseline intracranial pressure (ICP) in response to a variety of noxious and noxious stimuli.

Compromise in intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of noxious and non-noxious stimuli.

Defining characteristics

• Repeated increases in ICP of more than 10 mmHg for more than 5 minutes after any of a wide variety of external stimuli.
• Disproportionate increase in ICP after a single environmental stimulus or a single care maneuver.
• High ICP P2 curve.
• Variation of the volume / pressure response test: volume / pressure ratio 2, pressure-volume ratio & lt; 10.
• Baseline ICP equal to 10 mmHg, or higher.
• Widening of the ICP curve.

Related factors

• Brain injuries.
• Sustained increase in ICP between 10 and 15 mmHg.
• Decrease in cerebral perfusion pressure ≤ 50 to 60 mmHg.
• Systemic hypotension with intracranial hypertension.

Associated condition

• Brain injury
• Decrease in cerebral perfusion ≤ 50-60 mmHg
• Sustained increase in intracranial pressure (ICP) of 10-15 mmHg – Systemic hypotension with intracranial hypertension

NOC

• Electrolyte balance and acid base.
• Water balance.
• Neurological status.
• Neurological state: consciousness.

NIC

• Electrolyte management.
• Fluid / electrolyte management.
• Management of cerebral edema.
• Improved cerebral perfusion.
• Monitoring of intracranial pressure.
• Neurological monitoring.

This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless additional work is completed to bring it up to a level of evidence 2.1 or higher.

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