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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Ineffective cerebral During the whole course of INDEPENDENT: After the whole
O= Received patient tissue perfusion ICU admission, the patient Monitor temperature. Administer tepid Fever may reflect damage to hypothalamus. course of ICU
on bed, awake, related to will demonstrate improved sponge bath in presence of fever. Increased metabolic needs and oxygen admission, the
conscious with decreased arterial vital signs and absence of consumption occur (especially with fever and patient was able to
intravenous fluid of or venous blood signs of increased ICP. Monitor Intake and output. Weigh as demonstrate
shivering), which can further increased ICP.
flow. indicated. Note skin turgor, status, and improved vital signs
# 1 D5 0.3% NaCl
mucous membrane. and absence of signs
500cc @ KVO, Useful indicators of body water, which is an of increased ICP.
infusing well at left Maintain head or neck in midline or in integral part of tissue perfusion.
arm. neutral position, support with small towel
> With rolls and pillows. Avoid placing head on
ventriculostomy tube large pillows. Turning bed to one side compresses the jugular
freely draining to veins and inhibits cerebral venous drainage that
blood bag; dressing may cause increased ICP.
is dry and intact.
> With traeostomy Provides rest periods between care of Continual activity can increase ICP by producing
attached to activities and limit duration of procedures. a cumulative stimulant effect.
mechanical
ventilator, with FIO2
of 80%. Decrease extraneous stimuli and provide Provides calming effect, reduces adverse
> With nasogastric comfort measures such as back physiological response, and promotes rest.
tube for feeding. massage, quiet environment, gentle
WBC= 20T touch.
RBC= 3.5
million/uL Help patient avoid or limit coughing, These activities increase intrathoracic and intra-
> With the following crying, vomiting, and straining at stool. abdominal pressure.
vital signs of: Reposition the patient slowly.
>T=36.5oC.
>P=100bpm. Promotes venous drainage from head, reducing
Elevate the head of bed gradually to 15-
>R= 22 cpm. cerebral congestion and edema and increased ICP.
30 degrees as tolerated or indicated.
>BP=130/80mmhg

COLLABORATIVE:
Diuretics may be used in acute phase to draw
Administer diuretics as indicated. water from brain cells, reducing cerebral edema
and ICP.

Reduces hypoxemia, which may increase cerebral


Administer supplemental oxygen as vasodilation and blood volume.
indicated.