Anda di halaman 1dari 2

Cues Background Nursing Objective Intervention Rationale Evaluation

Knowledge Diagnosis
Objetive: Intracerebral Self-Care Long-term: Independent: The resources
hemorrhage is focal Deficit in Resources will • Place were
 Inability to bleeding from a blood bathing be identify patient in identified
vessel in the brain /hygiene, which are optimal which are
feed self
parenchyma. The cause
independent dressing useful in position for • Patients may useful in
is usually hypertension.
ly Blood from an /grooming, optimizing feeding take longer to optimizing
 Inability intracerebral feeding and the • Provide dress the
to dress self hemorrhage accumulates toileting related autonomy privacy during • These reduce autonomy
independent as a mass that can to and dressing. energy and
ly dissect through and neuromuscular independenc • Provide expenditure independenc
 Inability compress adjacent brain impairment, e of the frequent e of the
to bathe and tissues, causing neuronal secondary to patient assistance as • This ensures patient in her
groom self dysfunction. Large cerebrovascula needed with easier dressing hygiene,
hematomas increase r accident dressing. and comfort dressing or
independent
intracranial pressure.
ly (CVA) • Use of clothing • The need for grooming,
Pressure from
 Inability supratentorial one size privacy is feeding and
to perform hematomas and the larger. fundamental in toileting.
toileting accompanying edema • Maintain for most
tasks may cause transtentorial privacy during patients
independent brain herniation, bathing as • Clothing that is
ly compressing the brain appropriate. difficult to get
stem and often causing • Assist patient in and out of
secondary hemorrhages in removing or may
 Inability
in the midbrain and replacing compromise a
to ambulate pons. If the hemorrhage
independent necessary patient’s
ruptures into the
ly ventricular system, blood clothing. ability to be
may cause acute continent
hydrocephalus.
Cerebellar hematomas • Mechanic
that are > 3 cm in Collaborative: al problems
diameter may cause • Assure may prohibit
midline shift or that the patient
herniation. Herniation, consistency of from eating.
midbrain or pontine diet is
hemorrhage,
appropriate for
intraventricular
hemorrhage, acute patient’s ability
hydrocephalus, or to chew and
dissection into the brain swallow, as
stem can impair assessed by
consciousness and cause speech
coma and death. therapist.