Meniana Althea Marie 2 years and 7 months

RANK NURSING
DIAGNOSIS
JUSTIFICATION


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Ineffective cerebral tissue
perfusion related to decreased
arterial or venous blood flow.












Decreased Intracranial Adaptive
Capacity r/t Space- Occupying
Lesion











Knowledge Deficit: parents related
to illnesses suffered by children

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC
EXPLANATION
PLANNING NURSING
INTERVENTIONS
RATIONALE EVALUATION

Subjective:
Napansin ko na hindi
normal ang laki ng ulo
ng anak ko as
verbalized by the
mother.

Objective:
Restlessness
Irritability

VS:
Temp 36.5
PR 113
RR - 25

Ineffective cerebral
tissue perfusion
related to decreased
arterial or venous
blood flow.
Perfusion is the
process of nutritive
delivery of arterial
blood to a capillary
bed in the biological
tissue. When a lump
or a mass occluded
blood vessels or
capillaries, these will
result to ineffective
nutrition of the
affected part thus,
may result to loss of
function of the said
part and later on
affect to body
systematically. The
Frontal lobe of the
brain is responsible for
memory,
emotion/behaviors,
and motor function;
damagesto this area
may result to
behavioral changes,
loss of memory, and
paralysis. In the event,
damages happen to
the frontal lobe, it will
lead to restlessness,
which may contribute
to susceptibility to
After 8 hours of
nursing interventions,
the patient will
demonstrate
improved vital signs
and absence of signs
of increased ICP
Monitor
temperature
Administer
tepid sponge
bath in
presence of
fever



Monitor intake
and output
weigh as
indicated.
Note skin
turgor, status,
and mucous
membrane


Maintain head
or neck in
midline or
neutral
position,
support with
small towel
rolls and
pillows. Avoid
placing head
on large
pillows
Fever may
reflect damage
to
hypothalamus.
Increased
metabolic
need and
oxygen
consumption
occur.
Useful
indicators of
body water,
which is an
integral part of
tissue
perfusion.



Turning bed to
one side
compresses
the jugular
veins and
inhibits
cerebral
venous
drainage that
may cause
increased ICP

After 8 hours of
nursing interventions,
the patient was able
to demonstrate
improved vital signs
and absence of signs
of increased ICP
injury, it may also
result paralysis. When
ineffective perfusion
to the frontal lobe
occurs, this will lead to
loss of function of the
frontal lobe that will
greatly affect the
body, which may lead
to respiratory/cardiac
arrest since motor
function includes
muscle contraction.


Provide rest
periods
between care
of activities
and limit
duration of
procedures

Decrease
extraneous
stimuli and
provide
measures such
as back
massage, quiet
environment,
and gentle
touch.

Help patient
avoid or limit
coughing,
crying,
vomiting, and
straining at
stool.
Reposition the
patient slowly

Elevate the
head of bed
gradually to 15
30 degrees

Continual
activity can
increase ICP by
producing a
cumulative
stimulant
effect.

Provides
calming effect,
reduces
adverse
physiological
response, and
promotes rest.




These
activities
increase
intrathoracic
and intra-
abdominal
pressure



Promotes
venous
drainage from
head, reducing
as tolerated or
indicated
cerebral
congestion
and edema
and increased
ICP


ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

S>O> the pt.
manifested the ff.
Altered mental
status
Speech
abnormalities
Restlessness
Changes in
mental state
AEB (-) pupil
reaction to
light, flexion on
pain, no verbal
response.

Decreased
Intracranial
Adaptive Capacity
r/t Space-
Occupying Lesion
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
I. Short term:
After 1-2 of NI the SO
will be able to
understand the
clients condition and
be able perform
actively in promoting
the clients condition
having now a higher
level of
understanding of the
clients condition and
complications that
may occur.
Long term:
After 6-7 days of NI
the client will be able
to demonstrate stable
ICPAEB normalization
of pressure
waveforms/response
to stimuli
Establish rapport
Monitor VS
Monitor/document
changes in ICP wave
form and responses to
stimuli.
Assess eye opening
and
position/movement,
Pupils (size, equality,
and light reactivity),
purposeful and non-
purposeful motor
response comparing
left and right sides,
presence of reflexes,
nuchal rigidity,
consciousness and
mental state.
Provide information
about the clients
condition including the
complications which
To gain the
client and SOs
trust.
To obtain data
for
comparison.
To alter care
appropriately.
To note
degree of
impairment
To increase
SOs
understanding
of the clients
condition and
will be able to
decide
properly for
the clients
care.
To promote
circulation/ve
The SO shall have
understand the
clients condition and
be able perform
actively in promoting
the clients condition
having now a higher
level of
understanding of the
clients condition and
complications that
may occur. The client
shall have
demonstrated stable
ICP AEB or
malefaction of
pressure
waveforms/response
to stimuli.
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.

may arise once
untreated
Elevate HOB and
maintain head/neck in
midline/neutral
position
Decrease extraneous
stimuli/provide
comfort measures
Limit activities that
increases
intrathoracic/
abdominal pressure
Administer
medications as
ordered (e.g.
antihypertensive,
diuretics, analgesics,
antipyretics,
vasopressors, ant
seizure, neuromuscular
blocking agents, and
corticosteroids)
Prepare pt. for surgery
as indicated (Space
Occupying
Lesion)>Refer
accordingly
nous drainage
To reduce CNS
stimulation
and promote
relaxation.
To decrease
factors which
may
contribute in
further
increasing
ICP.>To
pharmacologic
ally manage
clients
condition and
maintain
homeostasis>
To reduce ICP
and enhance
circulation>To
have a
continuous
clients care