NURSING CARE PLAN

Assessment Diagnosis Planning Interventions Rationale Evaluation

Risk for
ineffective
cerebral tissue
perfusion related
to Hypertension.

After 8 hours of
Nursing
Interventions
the patient will
be able to have
effective
cerebral tissue
perfusion.

Assess vital
signs







Assess
oxygenation



Position head
slightly
elevated and
in neutral
position.





Provide quiet,
restful
environment






Administer
medication as
indicated


Assess skin
color and
temperature

This serve as
the baseline
data to know if
there is
alteration in
the patients
physiologic
functioning.

Oxygenation
affects
cerebral
functioning

Reduces
arterial
pressure by
promoting
venous
drainage and
may improve
cerebral
perfusion

Continual
stimulation
can increase
ICP, prevent
rebleeding in
the case of
hemorrhage


Provides
pharmacologic
al action for
the condition.

Cold clammy
skin is
secondary to
compensatory
increase in
sympathetic
nervous
system,
stimulation
and low
cardiac output
and
desaturation.



After 8 hours of
nursing
interventions
the patient was
able to have
effective
cerebral tissue
perfusion.