Cva, Ineffective

ASSESSMENT O= Received patient on bed, awake, conscious with intravenous fluid of # 1 D5 0.3% NaCl 500cc @ KVO, infusing well at left arm. > With ventriculostomy tube freely draining to blood bag; dressing is dry and intact. > With traeostomy attached to mechanical ventilator, with FIO2 of 80%. > With nasogastric tube for feeding. WBC= 20T RBC= 3.5 million/uL > With the following vital signs of: >T=36.5oC. >P=100bpm. >R= 22 cpm. >BP=130/80mmhg

DIAGNOSIS

PLANNING

INTERVENTION

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

During the whole course of ICU admission, the patient will demonstrate improved vital signs and absence of signs of increased ICP.

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

RATIONALE Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen consumption occur (especially with fever and shivering), which can further increased ICP. 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.

Provides rest periods between care of activities and limit duration of procedures.

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.

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

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

These activities increase intrathoracic and intraabdominal pressure.

Elevate the head of bed gradually to 1530 degrees as tolerated or indicated. COLLABORATIVE: Administer diuretics as indicated.

Administer supplemental oxygen as indicated.

Promotes venous drainage from head, reducing cerebral congestion and edema and increased ICP.

Diuretics may be used in acute phase to draw water from brain cells, reducing cerebral edema and ICP. Reduces hypoxemia, which may increase cerebral vasodilation and blood volume.

EVALUATION After the whole course of ICU admission, the patient was able to demonstrate improved vital signs and absence of signs of increased ICP.