Nursingcrib.com – Student Nurses’ CommunityNURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

“Napansin ko na hindi normal ang laki ng ulo ng anak ko” (My son’s head is abnormally large) as verbalized by the mother.

OBJECTIVE:

• Restlessness• Irritability• Changes in

vital signs• V/S taken as

follows:

T: 37.5P: 90R: 22

Ineffective cerebral tissue perfusion related to decreased arterial or venous blood flow.

Hydrocephalus is characterized by an abnormal increase in cerebrospinal fluid (CSF) volume within the intracranial cavity and by enlargement of the head in infancy. Pressure from increased fluid volume can damage the brain tissue. Hydrocephalus results from two major causes: obstruction of CSF flow (noncommunicating hydrocephalus) or faulty CSF absorption or overproduction of CSF (communicating hydrocephalus). In the noncommunicating type, obstruction may result from congenital defects, infections, trauma, spontaneous intracranial bleeding, and neoplasms. In the communicating type, faulty CSF absorption may result from

• After 8 hours of nursing interventions, the patient will demonstrate improved vital signs and absence of signs of increased ICP.

INDEPENDENT:• Monitor

temperature. Administer tepid sponge bath in presence of fever.

• Monitor Intake and output. Weigh as indicated. Note skin turgor, status, and mucous membrane.

• Maintain head or neck in midline or in neutral position, support with small towel rolls and pillows. Avoid placing head on large pillows.

• Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen consumption occur (especially with fever and shivering), which can further increased ICP.

• Useful indicators of body water, which is an integral part of tissue perfusion.

• Turning bed to one side compresses the jugular veins and inhibits cerebral venous drainage that may cause

• After 8 hours of nursing interventions, the patient was able to demonstrate improved vital signs and absence of signs of increased ICP.

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meningeal adhesions or excessive production of CSF fluid caused by a tumor or from unknown causes. Complications of hydrocephalus includes seizures, spontaneous arrest due to natural compensatory mechanisms, persistent increased intracranial pressure (ICP), brain herniation, developmental delays.

• Provides rest periods between care of activities and limit duration of procedures.

• Decrease extraneous stimuli and provide comfort measures such as back massage, quiet environment, gentle touch.

• Help patient avoid or limit coughing, crying, vomiting, and straining at stool. Reposition the patient slowly.

• Elevate the head of bed gradually to 15-30 degrees as tolerated or indicated.

increased ICP.

• Continual activity can increase ICP by producing a cumulative stimulant effect.

• Provides calming effect, reduces adverse physiological response, and promotes rest.

• These activities increase intrathoracic and intra-abdominal pressure.

• Promotes venous drainage from head, reducing cerebral congestion and edema and increased ICP.

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COLLABORATIVE:• Administer

diuretics as indicated.

• Administer supplemental oxygen as indicated.

• Diuretics may be used in acute phase to draw water from brain cells, reducing cerebral edema and ICP.

• Reduces hypoxemia, which may increase cerebral vasodilation and blood volume.