Assessment S

=

Diagnosis

Rationale

Planning Goal: After 6 hours of nursing intervention: Client will maintain VS within normal range.

Intervention Monitor Neurologic status and compare with baseline .

Rationale To monitor for neurologic deterioration and trends in level of consciousness. It is an indicator of cerebral perfusion. BP should be maintained 150mmhg. To monitor LOC.

Evaluation After 6 hours of nursing intervention:

Ineffective tissue Decrease in perfusion(cerebral) oxygen resulting in r/t bleeding. the failure to nourish the tissues at the capillary level.

O= Monitor VS(BP, pulse,LOC).

Monitor papillary response and motor function hourly. Monitor Respiratory status

Because a reduction in oxygen in areas of the brain with impaired autoregulation increases the chance of cerebral infarction.

Provide stool softeners. To promote venous drainage and decrease ICP. straining. Elevate head of bed 15-30 degrees. . low fat and soft diet. To avoid increase in BP and obstructed venous return. Administer medications. Provide low salt. Visitors are restricted. To keep the patient as quiet as possible.Maintain bed rest. Avoid activities that requires exertion(valsalva maneuver. forceful sneezing). To avoid constipation and decrease straining. Activities may elevate BP increases the risk for bleeding.

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