ASSESSMENT

Objective: -immobility - bulging fontanels - muscle weakness - GCS of E4V1M4

DIAGNOSIS Ineffective cerebral tissue perfusion

Mrs. A/68 years old/PGO 20 to POA vs. Diverticulitis INFERENCE PLANNING INTERVENTION Tumor After 4 hrs. of Provide tepid nursing Sponge Bath interventions, Asses fluid loss mass in the brain the patient will and facilitate maintain core oral intake temperature Promote bed within normal intracranial rest range. pressure Provide cool circulating air using a fan Constriction of blood Assist patient in vessels changing into dry clothing Provide hygienic blood flow in brain care Monitor vital oxygenation and signs glucose supply Maintain IV fluids as ordered by physician Administer anti pyretic as ordered Monitor hematologic test and other pertinent lad

RATIONALE Enhances heat loss by evaporatio n and conduction

EVALUATION

After 4 hrs. of nursing intervention s, the patient was able maintain Increases core metabolic temperature rate and within diaphoresis normal Reduces range. body heat production Dissipates heat by convection Increases comfort Prevents herpetic lesions of the mouth Notes progress and changes of condition Prevents dehydration

results Discuss condition of the patient with other members of the health care team

Reduces fever Treats underlying cause Indicates presence of infection and dehydration Ensures continuous intervention