Ncp - Ineffective Cerebral Tissue Perfusion R/t Space Occupying Lesion (neuroblastoma On Frontal Lobe)
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ASSESSMENT
NURSING DIAGNOSIS
S>Ø O> the pt. manifested the ff.
Ineffective Cerebral Tissue Perfusion r/t Space Occupying Lesion (Neuroblastoma on Frontal Lobe)
Altered mental status Speech abnormalities Restlessness Changes in pupillary reaction AEB (-) pupil reaction to light.
SCIENTIFIC EXPLANATION Perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. When a lump or a mass occluded blood vessels or capillaries, these will result to ineffective nutrition of the affected part thus, may result to loss of function of the said part and later on affect to body systematically. The Frontal lobe of the brain is responsible for memory, emotion/behaviors, and motor function; damages to this area may result to behavioral changes, loss of memory, and paralysis. In the event, damages happen to the frontal lobe, it will lead to restlessness, which may contribute to susceptibility to injury, it may also result paralysis. When ineffective perfusion to the frontal lobe occurs, this will lead to loss of function of the frontal lobe that will greatly affect the body, which may lead to respiratory/cardiac arrest since motor function includes muscle contraction.
PLANNING
INTERVENTIONS
Short term:
>Establish rapport
After 4-5° of NI, the client and the SO will be able to verbalize understanding of condition, therapy regimens, and when to contact healthcare provider.
>Monitor VS. >Reviewed laboratory results >Determine factors r/t individual situation >Assess mood changes, memory and motor changes >Provide information regarding the client’s condition.
Long term: After 6-7 days of NI the client will be able to demonstrate increased perfusion as individually appropriate AEB VS are on client’s normal range, alert and oriented.
>Note Hx. of brief/intermittent periods of confusion/blackout. >Interview SO regarding their perception of situation >Review medication. >Elevate HOB and maintain head/neck in midline/neutral position >Administer medications as ordered >Prepare pt. for surgery as indicated (Space Occupying Lesion) >Refer to ND Decreased Intracranial Adaptive Capacity >Refer accordingly
RATIONALE >To gain the client and SO’s trust. >To obtain data for comparison. >To evaluate underlying causes. >To assess contributing factor. >To note degree of impairment >To increase the SO’s knowledge about the dse. condition. >To evaluate occurrence of TIA >To assist SO in understanding the client’s condition. >To evaluate possible adverse effect to the client’s condition. >To promote circulation/venous drainage >To pharmacologically manage client’s condition. >To maximize tissue perfusion. >To manage other actual client’s problem >To have a continuous client’s care
EXPECTED OUTCOME The client and the SO shall have verbalized understanding of condition, therapy regimens, and when to contact healthcare provider. The client shall have demonstrated increased perfusion, as individually appropriate AEB VS are on client’s normal range, alert and oriented.
ASSESSMENT
NURSING DIAGNOSIS
S>Ø O> the pt. manifested the ff.
Ineffective Cerebral Tissue Perfusion r/t Space Occupying Lesion (Neuroblastoma on Frontal Lobe)
Altered mental status Speech abnormalities Restlessness Changes in pupillary reaction AEB (-) pupil reaction to light.
SCIENTIFIC EXPLANATION Perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. When a lump or a mass occluded blood vessels or capillaries, these will result to ineffective nutrition of the affected part thus, may result to loss of function of the said part and later on affect to body systematically. The Frontal lobe of the brain is responsible for memory, emotion/behaviors, and motor function; damages to this area may result to behavioral changes, loss of memory, and paralysis. In the event, damages happen to the frontal lobe, it will lead to restlessness, which may contribute to susceptibility to injury, it may also result paralysis. When ineffective perfusion to the frontal lobe occurs, this will lead to loss of function of the frontal lobe that will greatly affect the body, which may lead to respiratory/cardiac arrest since motor function includes muscle contraction.
PLANNING
INTERVENTIONS
Short term:
>Establish rapport
After 4-5° of NI, the client and the SO will be able to verbalize understanding of condition, therapy regimens, and when to contact healthcare provider.
>Monitor VS. >Reviewed laboratory results >Determine factors r/t individual situation >Assess mood changes, memory and motor changes >Provide information regarding the client’s condition.
Long term: After 6-7 days of NI the client will be able to demonstrate increased perfusion as individually appropriate AEB VS are on client’s normal range, alert and oriented.
>Note Hx. of brief/intermittent periods of confusion/blackout. >Interview SO regarding their perception of situation >Review medication. >Elevate HOB and maintain head/neck in midline/neutral position >Administer medications as ordered >Prepare pt. for surgery as indicated (Space Occupying Lesion) >Refer to ND Decreased Intracranial Adaptive Capacity >Refer accordingly
RATIONALE >To gain the client and SO’s trust. >To obtain data for comparison. >To evaluate underlying causes. >To assess contributing factor. >To note degree of impairment >To increase the SO’s knowledge about the dse. condition. >To evaluate occurrence of TIA >To assist SO in understanding the client’s condition. >To evaluate possible adverse effect to the client’s condition. >To promote circulation/venous drainage >To pharmacologically manage client’s condition. >To maximize tissue perfusion. >To manage other actual client’s problem >To have a continuous client’s care
EXPECTED OUTCOME The client and the SO shall have verbalized understanding of condition, therapy regimens, and when to contact healthcare provider. The client shall have demonstrated increased perfusion, as individually appropriate AEB VS are on client’s normal range, alert and oriented.
NURSING DIAGNOSIS
S>Ø O> the pt. manifested the ff.
Ineffective Cerebral Tissue Perfusion r/t Space Occupying Lesion (Neuroblastoma on Frontal Lobe)
Altered mental status Speech abnormalities Restlessness Changes in pupillary reaction AEB (-) pupil reaction to light.
SCIENTIFIC EXPLANATION Perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. When a lump or a mass occluded blood vessels or capillaries, these will result to ineffective nutrition of the affected part thus, may result to loss of function of the said part and later on affect to body systematically. The Frontal lobe of the brain is responsible for memory, emotion/behaviors, and motor function; damages to this area may result to behavioral changes, loss of memory, and paralysis. In the event, damages happen to the frontal lobe, it will lead to restlessness, which may contribute to susceptibility to injury, it may also result paralysis. When ineffective perfusion to the frontal lobe occurs, this will lead to loss of function of the frontal lobe that will greatly affect the body, which may lead to respiratory/cardiac arrest since motor function includes muscle contraction.
PLANNING
INTERVENTIONS
Short term:
>Establish rapport
After 4-5° of NI, the client and the SO will be able to verbalize understanding of condition, therapy regimens, and when to contact healthcare provider.
>Monitor VS. >Reviewed laboratory results >Determine factors r/t individual situation >Assess mood changes, memory and motor changes >Provide information regarding the client’s condition.
Long term: After 6-7 days of NI the client will be able to demonstrate increased perfusion as individually appropriate AEB VS are on client’s normal range, alert and oriented.
>Note Hx. of brief/intermittent periods of confusion/blackout. >Interview SO regarding their perception of situation >Review medication. >Elevate HOB and maintain head/neck in midline/neutral position >Administer medications as ordered >Prepare pt. for surgery as indicated (Space Occupying Lesion) >Refer to ND Decreased Intracranial Adaptive Capacity >Refer accordingly
RATIONALE >To gain the client and SO’s trust. >To obtain data for comparison. >To evaluate underlying causes. >To assess contributing factor. >To note degree of impairment >To increase the SO’s knowledge about the dse. condition. >To evaluate occurrence of TIA >To assist SO in understanding the client’s condition. >To evaluate possible adverse effect to the client’s condition. >To promote circulation/venous drainage >To pharmacologically manage client’s condition. >To maximize tissue perfusion. >To manage other actual client’s problem >To have a continuous client’s care
EXPECTED OUTCOME The client and the SO shall have verbalized understanding of condition, therapy regimens, and when to contact healthcare provider. The client shall have demonstrated increased perfusion, as individually appropriate AEB VS are on client’s normal range, alert and oriented.
ASSESSMENT
NURSING DIAGNOSIS
S>Ø O> the pt. manifested the ff.
Ineffective Cerebral Tissue Perfusion r/t Space Occupying Lesion (Neuroblastoma on Frontal Lobe)
Altered mental status Speech abnormalities Restlessness Changes in pupillary reaction AEB (-) pupil reaction to light.
SCIENTIFIC EXPLANATION Perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. When a lump or a mass occluded blood vessels or capillaries, these will result to ineffective nutrition of the affected part thus, may result to loss of function of the said part and later on affect to body systematically. The Frontal lobe of the brain is responsible for memory, emotion/behaviors, and motor function; damages to this area may result to behavioral changes, loss of memory, and paralysis. In the event, damages happen to the frontal lobe, it will lead to restlessness, which may contribute to susceptibility to injury, it may also result paralysis. When ineffective perfusion to the frontal lobe occurs, this will lead to loss of function of the frontal lobe that will greatly affect the body, which may lead to respiratory/cardiac arrest since motor function includes muscle contraction.
PLANNING
INTERVENTIONS
Short term:
>Establish rapport
After 4-5° of NI, the client and the SO will be able to verbalize understanding of condition, therapy regimens, and when to contact healthcare provider.
>Monitor VS. >Reviewed laboratory results >Determine factors r/t individual situation >Assess mood changes, memory and motor changes >Provide information regarding the client’s condition.
Long term: After 6-7 days of NI the client will be able to demonstrate increased perfusion as individually appropriate AEB VS are on client’s normal range, alert and oriented.
>Note Hx. of brief/intermittent periods of confusion/blackout. >Interview SO regarding their perception of situation >Review medication. >Elevate HOB and maintain head/neck in midline/neutral position >Administer medications as ordered >Prepare pt. for surgery as indicated (Space Occupying Lesion) >Refer to ND Decreased Intracranial Adaptive Capacity >Refer accordingly
RATIONALE >To gain the client and SO’s trust. >To obtain data for comparison. >To evaluate underlying causes. >To assess contributing factor. >To note degree of impairment >To increase the SO’s knowledge about the dse. condition. >To evaluate occurrence of TIA >To assist SO in understanding the client’s condition. >To evaluate possible adverse effect to the client’s condition. >To promote circulation/venous drainage >To pharmacologically manage client’s condition. >To maximize tissue perfusion. >To manage other actual client’s problem >To have a continuous client’s care
EXPECTED OUTCOME The client and the SO shall have verbalized understanding of condition, therapy regimens, and when to contact healthcare provider. The client shall have demonstrated increased perfusion, as individually appropriate AEB VS are on client’s normal range, alert and oriented.
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