Nursing Diagnosis Rationale Interventions Rationale Evaluation
Ineffective cerebral tissue Definition: INDEPENDENT: INDEPENDENT: Goal partially Met
perfusion r/t interruption Decrease in cerebral 1. Assess contributing factor 1. To determine and influence the After 8 hours of
of blood flow by space tissue circulation to that cause for decreased choice of interventions. nursing intervention the
occupying lesion which may compromise cerebral perfusion and Deterioration in neurological patient improved level
(hemorrhages, health. potential for increased ICP. signs or failure to improve after of tissue perfusion as
hematoma) aeb loss of Pathophysiology 2. Assess higher functions, initial insult may reflect evidence by:
consciousness with GCS Cerebral hemorrhage including speech, if patient is decreased intracranial adaptive
score of 3/15. alert. capacity requiring patient to be Bilaterally
Resulting in damage to 3. Monitor and record vital transferred to critical area for reactive pupils
O: signs and + corneal
brain tissue. monitoring of ICP, other
GCS Score of 4. Monitor and record I and O reflex
3/15 therapies.
5. Perform GCS monitoring by CPP of 3-4 and
Unequal pupil Disruption of blood 2. Changes in cognition and speech
assessing patient’s response 70-75 mmHg
size 4 mm loss of supply to the brain. content are an indicator of
according to three aspects of GCS scoring of
pupillary reaction responsiveness: eye opening, location and degree of cerebral
5/15
Decreased LOC Decrease O2 motor, and verbal response involvement and may indicate
Stable vital
Cerebral edema 6. Check capillary refill and deterioration or increased ICP.
signs
of 5.3-mm left to Failure to nourish the conjunctiva for paleness 3. Have a baseline data and monitor
right midline tissues at the capillary 7. Elevate head of bed possible changes that might
shift. level. 8. Avoid neck flexion and cause further complications.
ICP 14 mmHg extreme hip/knee extension 4. Determine fluid volume relative
Changes in vital Decrease perfusion 9. Prevent straining at stool, to oxygen transportation and
signs. throughout the body. holding breath circulation
BP=221/105 10. Encourage relaxation 5. To detect changes indication of
HR=28 bpm Ineffective cerebral tissue worsening or improving
perfusion condition
GOAL: 6. Determine blood circulation
Within 8 hours of nursing DEPENDENT/COLLABORATIVE
REFERENCES: 7. To promote circulation
intervention the patient :
Nurse’s Pocket Guide 8. Avoid obstruction of arterial and
will improve level of 1. Administer Atropine sulfate
15th Edition venous blood flow
tissue perfusion. 0.5mg/ 1ml IVTT OD as
By: Marilynn E. Doenges 9. Valsalva maneuver increases ICP
order by the physician.
Mary Frances and potentiates risk of re
2. Administer Nicardipine
Moorhouse Alice C. bleeding.
hydrochloride 5ml/ hour per
Murr 10. Decrease tissue O2 demand
200ml IVTT q8h as order.
Pages. 294
3. Follow up laboratory results.
DEPENDENT/COLLABORATIVE:
1. It can temporarily revert sinus
bradycardia to
normal sinus rhythm and reverse
AV nodal blocks by removing
vagal influences.
2. To treat hypertension to prevent
increased risk of extension of
tissue damage
3. To determine severity of
hemorrhage, cerebral edema, or
shift of midline structure,
possible seizure activity, possible
increased of ICP, and fracture
that might cause occurrence of
further complications.
REFERENCES:
Nurse’s Pocket Guide 15th Edition
By: Marilynn E. Doenges
Mary Frances Moorhouse
Alice C. Murr
Pages. 295-297
Nursing Diagnosis Rationale Interventions Rationale Evaluation
Ineffective airway Definition: INDEPENDENT: INDEPENDENT: Goal Met
clearance r/t presence of Ineffective 1. Assess for airway 1. Maintaining patent airway
artificial airway aeb by airway clearance occurs patency. clearance is always the first After 8 hours of nursing
ineffective cough. when the body loses the 2. Auscultate breath priority especially in cases intervention patient
O: ability to maintain a sounds. like trauma or neurological maintain airway clear,
ICP 14 mmHg patent airway. 3. Monitor vital signs decomposition. open airways as evidence
Abnormal heart Pathophysiology including changes in 2. Abnormal breath sounds by normal rate, depth of
rate, rhythm and Presence of artificial HR, BP, and may indicate ineffective respirations, and ability to
depth. airway temperature. Respiratory airway clearance. demonstrate increased air
Decreased LOC pattern including rate, 3. To determine abnormal exchange as evidence by:
Intubated Ineffective cough depth and effort. findings on respiration.
Reduced cough Including blood gas Increased work of O2 saturation of 97
reflex values and pulse. Use breathing can lead to %
Inability to protect the
Inability to remove pulse oximetry to tachycardia and Reduced excessive
patent airway and
airway secretions. monitor oxygen hypertension. Retained secretion
secretions clearance
saturation; assess arterial secretions or atelectasis
O2 saturation of GCS of 10/15
blood gases. may be a sign of an
87% Retention of secretions No adventitious
4. Note for mental status. inflammatory process
Excessive breath sound
5. Position client in upright manifested by a fever or
secretions
Ineffective airway position if tolerated to increased temperature
Bradycardia clearance optimize respiration. Pulse oximetry is used to
Changes in vital 6. Check cough and gag detect changes in
signs. Reference/s: reflex. oxygenation, an oxygen
BP=221/105 Nurse’s Pocket Guide 7. Provide suctioning; if saturation less than 90%
HR=28 bpm 15th Edition patient is able, assist indicates problems in
By: Marilynn E. Doenges with turning, coughing, oxygenation.
GOAL/PLAN
Mary Frances and deep breathing. 4. Increasing lethargy,
Within 8 hours of nursing Moorhouse confusion and irritability
intervention patient will Alice C. Murr can be initial signs of
maintain clear, open Pages. 27 DEPENDENT/COLLABORA cerebral hypoxia.
airways as evidence by TIVE: 5. An upright position allows
1. Administer Mannitol maximal air exchange and
normal rate, depth of
30g/ tab BID IVP as lung expansion with
respirations, and ability to
order by the physician. increase oxygenation. It
demonstrate increased air 2. Administer Oxygen also reduce aspirating oral
exchange. (O2) therapy as secretions and prevent oral
prescribe by the secretions.
physician. 6. Check cough and gag
3. Refer to the pulmonary reflex.
clinical nurse specialist, 7. To prevent pooling of
home health nurse, or secretions and to have
respiratory therapist as patent airway clearance.
indicated. DEPENDENT/COLLABORATI
4. Follow up laboratory VE:
results. 1. It creates an osmotic drive for
water to move into
the airway lumen.
2. Intubation and mechanical
ventilation (to provide controlled
hyperventilation to decrease
elevate ICP).
2. To promote a treatment option
known as pulmonary rehabilitation.
Consultants may be helpful in
ensuring that proper treatments are
met.
4. Provides accurate information
about severity of condition, and to
identify therapeutic level need.
Reference/s:
Nurse’s Pocket Guide 15th Edition
By: Marilynn E. Doenges Mary
Frances Moorhouse Alice C. Murr
Pages. 27-33
