NURSING CARE PLAN

Date Formulated: August 12, 2015

Nursing Diagnosis (NANDA Approved): Altered tissue perfusion related to Increased ICP resulting from meningeal
inflammation
Level of Prioritization: HIGH
Reason/Cause Analysis (Indicate your reference):
Goal: The child will be free from signs and symptoms of Increased intracranial pressure
CUES
DESIRED OUTCOME
NURSING
RATIONALE
EVALUATION
INTERVENTION
SUBJECTIVE:
SHORT TERM:
1. Elevate head
To promote
SHORT TERM:
After 8 hours of
of the bed (10After 8 hours of
circulation or
nursing intervention
30 degrees)
nursing intervention
venous
Headache
the patients
and maintain
the goal was met:
drainage
dizziness
significant others will
head or neck
the patients S.O
verbalize
in midline
verbalized
2. Instruct,
understanding of the
understanding of the
To decrease
demonstrate
present condition
the present condition
metabolic
and
and disease
and disease
OBJECTIVE:
conserves
encourage
management as well
manangement as
tissue O2
deep
as participate in
evidenced by full
Vomiting
demands
breathing
therapy regimen.
participation of
lethargic
exercises
and
therapy regimen.
Stiff neck
promote
a
photophobia
quiet and
LONG TERM:
LONG TERM:
Temp- 38
restful
After 24 hours of
Information
degree celcius After 24hours of
environment
nursing intervention
nursing inteverntin
necessary for
3.
Discuss
the child will be free
client to make the goal was
factors and
from signs and
partially met as
informed
potential
symptoms of
evidenced by
choices and
outcomes
of
Increased ICP as
absence of headache
commit to
the disease
evidenced by
and body temp.
lifestyle
condition
absence of vomiting,
within normal limits.
changes as
headache,
Patient still
appropriate
complaints of visual
complains of

disturbances and
Body temperature
within normal limits.

4. Identify
changes
related to
systemic and
or peripheral
alterations in
circulation

COLLABORATIVE:
5. Administer
medications
needed and to
report any
sign of
adverse
reactions.

To assess or
determine
causative or
contributing
factors

stiffneck, dizziness,
visual disturbances
and vomiting.