NURSING DIAGNOSIS NURSING INTERVENTIONS

1. Ineffective cerebral tissue perfusion INDEPENDENT:

related to decreased arterial or venous  Monitor temperature. Administer tepid
blood flow. sponge bath in presence of fever.

R: Fever may reflect damage to

hypothalamus. Increased metabolic
needs and oxygen consumption occur
(especially with fever and shivering),
which can further increased ICP.

 Monitor Intake and output. Weigh as

indicated. Note skin turgor, status, and
mucous membrane.

R: Useful indicators of body water,

which is an integral part of tissue
perfusion

 Maintain head or neck in midline or in

neutral position, support with small
towel rolls and pillows. Avoid placing
head on large pillows.

R: Turning bed to one side

compresses the jugular veins and
inhibits cerebral venous drainage that
may cause increased ICP.

 Provides rest periods between care of

activities and limit duration of
procedures.

R: Continual activity can increase ICP

by producing a cumulative stimulant
effect.

 Decrease extraneous stimuli and

provide comfort measures such as
back massage, quiet environment,
gentle touch.
 R: Provides calming effect, reduces
adverse physiological response, and
promotes rest.

 Elevate the head of bed gradually to

15-30 degrees as tolerated or
indicated.

R: Promotes venous drainage from

head, reducing cerebral congestion
and edema and increased ICP.

COLLABORATIVE:
 Administer diuretics as indicated.

R: Diuretics may be used in acute

phase to draw water from brain cells,
reducing cerebral edema and ICP.

 Administer supplemental oxygen as

indicated.

 R: Reduces hypoxemia, which may

increase cerebral vasodilation and
blood volume.