Assessment Subjective: Nahihilo ako tapos nanglalabo minsan ang paningin ko . As patient verbalized.

Objective: - decrease level of consciousness (GCS = 11) E- 3 V- 4 M- 4 -dizziness -right sided weakness -nausea and vomiting -restless -slurred speech -increased ICP

Nursing Diagnosis Ineffective cerebral tissue perfusion related to brain injury

Planning Short term: After 8 hours of nursing interventions the client will receive adequate perfusion and circulation of well-oxygenated blood. Long term: After 3 days of nursing interventions, the client will improve his GCS from 11 to 15

Intervention -elevate head of bed and maintain head and neck in neutral position

Rationale -to promote circulation and venous drainage and improve cerebral perfusion and circulation -patient is at risk of falls due to body weakness -to prevent further damage to the brain cells

Evaluation Goal met

-maintain side rails up

- instruct patient to avoid any strenuous action that may cause further increase in intracranial pressure such as coughing and sneezing -monitor the regulation of the mechanical ventilator -administer oxygen as prescribed

-to ensure adequate air with oxygen are compressed in the lungs -to prevent hypoxemia and to increase blood oxygenation