NURSING CARE PLAN

BACKGROUND
ASSESSMENT NURSING DIAGNOSIS GOALS OF CARE
KNOWLEDGE
Subjective: Ineffective cerebral tissue Risk factors: Short term goals:
“Mayroong namuong dugo sa utak niya perfusion related to
kaya hindi maayos ang daloy ng dugo increased ICP secondary to cerebral edema, After 5 hrs. of intervention, the
rito” as verbalized by the patient’s epidural hemorrhage patient is expected to have
mother. increased intracranial pressure, improved cerebral tissue perfusion,
Objectives: Or r/to brain trauma absence of signs of increased ICP
 GCS: 13 to 9 hemorrhage from cerebral vessel, such as episodes of seizure,
lowering level of consciousness, motor any complications will be
response, behavioral and pupil reaction Brain trauma prevented, and will demonstrate
stable vital signs.
 INDICATE - LEVEL OF (INC) : interruption of cerebral arterial
ICP or Describe signs of Inc in blood flow Long term goals:
ICP/Edema
After 2 days of intervention, the
 CT SCAN RESULT *Kunin sa Patho ni Chie* patient will maintain adequate
-Left temporal lobe contusions cerebral tissue perfusion, as
-Hypodensity of the brain evidenced by stable vital signs,
-Encephalomalacic change in addition to an stable/alert neurologic status, and
extradural fluid collection in the right frontal no decrease in level of
region consciousness.

He will also manifest normal ABGs

 Abnormal ABG result and will display no further
- pH (7.32) Low deterioration or recurrence of
- PaCO2 (47 mmHg) High deficits.
- PaO2 (78 mmHg) Low
- HCO3 (19 mEq/L) Low
- SpO2 (92%) Low

 Vital Signs:

BP: 170/90 mmHg

RR: 58 bpm
PR: 14 cpm
Temp: 37.2 C

INTERVENTION RATIONALE EVALUATION

INDEPENDENT: INDEPENDENT: Short term goals:

1. Assess for signs of decreased 1. Evaluation of Ineffective Tissue Perfusion After 5 hrs. of intervention, the patient didn’t
tissue perfusion. defining characteristics provides a baseline have any seizures and displayed no further
for future comparison. (HOW TO deterioration or recurrence of deficits, the
2. Performed neurologic assessment MEASURE OR ASSESS?) patient also manifested an improved level of
every 1 hour as needed. Noted ICP as evidenced by from ___ to ____
rapid changes or continued shifts 2. Review trend in level of consciousness (INDICATE ANONG VALUE/LEVEL NA)
in mental status. (LOC) and possibility for increased ICP and
is helpful in deciding location, extent and He also manifested an improvement in vital
- Monitored neurological status development/resolution or central nervous signs as evidenced by – Describe/Indicate
using Glasgow Coma Scale system (CNS) damage.
(GCS). Temp became normal from -
3. Hypertension is a major risk factor for both bp -
3. Monitored vital signs every 1 ischemic and haemorrhagic stroke. Rr -
hour as needed. Pr -
Fever may be a sign of damage to hypothalamus.
- Monitored blood pressure (BP) Fever and shivering can further increase ICP. the goal was partially met.
regularly
4. Elevating the head of the bed allows for Long term goals:
- Controlled increase in increased venous drainage that decreases
temperature as necessary. ICP. ---- make sure no c-spine injury After 2 days of intervention,
Performed tepid sponge bath.
5. Low brain PbtO2 is predictive of increased Client was able to demonstrate appropriate
4. Elevated head of bed 30 to 45 mortality in clients with severe TBI orientation to person, place, time, and situation.
degrees with head in midline
position. He demonstrated ability to follow simple
5. Monitored brain tissue oxygen DEPENDENT/COLLABORATIVE commands.
(PbtO2) \\\ & ABG INTERVENTIONS:
He has equal bilateral motor strength and has
6. Hyperosmolar therapy reduces brain water adequate swallowing ability
DEPENDENT/COLLABORATIVE content. A comparison of mannitol and
INTERVENTIONS: hypertonic saline found that multiple studies, Patient maintained alert level of consciousness,
6. Maintained euvolemia and including randomized controlled trials improved cognition, and motor/sensory
checked for optimal fluid balance. (RCTs), demonstrated superior effectiveness function. (ALERT NA BA SI PT AFTER 2
Administered D5NSS (3X) X 30 of hypertonic saline in decreasing ICP DAYS?)
cc/hr as ordered. However, the patient still has an inc level of
- Administered hypertonic saline - Sufficient fluid intake maintains adequate icp from ___ to ____ (INDICATE ANONG
(bolus or continuous infusion) per filling pressures; Electrolyte/acid-base VALUE/LEVEL NA)
collaborative protocol. variations, hypoxia, and systemic emboli
Therefore the goal was partially met.
influence cerebral perfusion.
7. Maintained glycemic control per
collaborative protocol. - Infusing intravenous fluids to sustain
normal circulating volume helps maintain
8. Administered Medications as normal cerebral blood flow.
prescribed by the physician.
 Mannitol 7. Maintain glucose levels between 110 and 180
 Dexamethasone mg/dL using insulin therapy in critically ill
 Ranitidine brain-injured clients. WHY
 Acetaminophen
8.
 Phenytoin (Dilantin),  Mannitol is given to the patient to reduce
phenobarbital. intracranial pressure and help treat edema.
 Nicardipine  Dexamethasone is given to stimulate the
synthesis of enzymes needed to decrease the
inflammatory response.
9. Monitored laboratory studies as  Ratinidine is indicated for patient with head
indicated: prothrombin time (PT) injury to maintain the acidity of gastric acid
and/or activated partial in the stomach.
thromboplastin time (aPTT) time,  Nicardipine is given to control blood pressure
Dilantin level. after traumatic brain injury (TBI) and frontal
subdural/epidural hemorrhage.
 Acetaminophen is given for management of
mild pain and possible fever.
10. Assisted in Craniotomy  Phenytoin is used to control seizures and/or
for sedative action. Note: Phenobarbital
enhances action of antiepileptics.
These reduce risk of seizure which may result
from cerebral edema or ischemia.
9. To assess the incidence and probable
development of coagulopathy because
coagulopathy frequently occurs following
traumatic brain injury (TBI) and usually
occurs 6–72-hour post-trauma. The incidence
and the probable risk factors for development
of coagulopathy and poor outcome following
TBI are largely unknown and vary
considerably.

10. The temporary removal of a portion of skull

has long been part of the neurosurgeon's
armamentarium for treating ICP elevation
resulting from TBI. ++ BETTER
RATIONALE