Problem: Ineffective cerebral tissue perfusion r/t increased intracranial pressure

Assessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Intervention
s
Rationale Expected
Outcome
S>

O>

The patient
manifested:

Restlessness
Irritable
Pale skin
Weakness

The patient may
manifest:

Paralysis
Speech
abnormalities
Altered LOC


Ineffective
cerebral
tissue
perfusion
r/t
increased
intracrania
l pressure
Since the
patient
suffers from
alteration in
the blood
flow in the
brain, the
presence of
blockage of
the blood
vessel can
be
multifactorial
. These can
be due to
hematoma
formation in
the subdural
space.
Decrease
elasticity of
the vessel
wall leading
to alteration
of blood
perfusion
with the
Short term:
After 4 hours
of nursing
intervention
s the patient
will
demonstrate
stable vital
signs and
absence of
signs of
increased ICP.




Long term:
After 3 days of
nursing
interventions
the patient
will have an
improve level
of
consciousness
, cognition
and
>Establish
rapport.





>Provide
comfort and
safety

>Monitor
vital signs


>Monitor
neurologic
status.



>Position
with head
slightly
elevated
and in
neutral
>To gain
patients
and s.os
trust and
cooperation
.

>To lessen
discomfort.


>To have
baseline
data.

>to have
baseline
data, assess
changes in
neurologic
status.

>Reduces
arterial
pressure by
promoting
venous
Short term:
The patient
shall have
demonstrated
stable vital
signs and
absence of
signs of
increased ICP.






Long term:
The patient
shall have an
improved
level of
consciousness
, cognition
and
motor/sensory
function.
initiation of
the clotting
sequence.
This may later
lead to the
developmen
t of
thrombus
which can
be loosened
and
dislodged in
some areas
of the brain
such as
cerebral
carotid
artery that
may lead to
alteration of
blood
perfusion.
motor/sensory
function.
position.






>Assess for
nuchal
rigidity,
increase
restlessness
and
irritability.


>Administer
medications
as
indicated.
drainage
and may
improve
cerebral
circulation.


>Indicative
of
meningeal
irritation esp.
in
hemorrhagic
disorder.

>To promote
wellness.