CC8CuL8A AuL LuML8 A

8Sn 31n

ASSLSSMLN1 NUkSING DIAGNCSIS LANNING NUkSING
IN1LkVLN1ICN
kA1ICNALL LVALUA1ICN

C8!LC1lvL uA1A
O SLuporous
O Skln ls sllghLly
pale
O Slugglsh pupll
reacLlon
O ml blood
loss
O 88 38 cpm
O 8 113 bpm
O 8 8$
O C saL 97
O 88C counL ls
low normal


lneffecLlve cerebral
Llssue perfuslon
relaLed Lo bleedlng
secondary Lo surgery

AL Lhe end of Lhe shlfL
Lhe cllenL wlll
lmprove perfuslon ln
Lhe braln as evldence
by
O vlLal slgns wlll
be ln normal
range
O Lnhance LCC


oslLlon wlLh head
sllghLly elevaLed
and ln neuLral
poslLlon




MonlLor and
documenL
neurologlcal sLaLus
and compare wlLh
basellne and
monlLor CCS

MonlLor vlLal slgns
every 13 mlns





romoLe bed resL
and provlde
envlronmenL LhaL ls
conduclve Lo Lhe

8educes arLerlal
pressure by
promoLlng venous
dralnage and may
lmprove cerebral
clrculaLlon and
perfuslon

1o know Lhe
condlLlon of Lhe
paLlenL and Lo know
lf lL ls lmprovlng or
noL


Changes ln vlLal
slgns may lndlcaLe
lmprovemenL or
worsenlng of Lhe
condlLlon of Lhe
paLlenL

ConLlnual
sLlmulaLlon
lncreases
lnLracranlal

Check vlLal slgns
every 13 mlns

Check level of
consclousness

Check pupll reacLlon




healLh of Lhe
paLlenL




AdmlnlsLer
supplemenLal
oxygen as
lndlcaLed

AdmlnlsLed lvl as
per docLor's order
pressure and
prevenL Lhe
occurrence of
rebleedlng


8educes hypoxemla




8leedlng decreases
Lhe amounL of
plasma and fluld ln
Lhe body