CUES NURSING NURSING EXPECTED

NURSING OBJECTIVES RATIONALE

Subjective/Objective DIAGNOSIS INTERVENTIONS OUTCOME
Objectives: Ineffective Cerebral After rendering independent Independent: After rendering of
 Altered mental status Tissue Perfusion and dependent nursing  Establish Rapport  To gain family and independent and
with GCS=12 related to Hematoma interventions during the whole client’s trust & dependent nursing
Eye=3 secondary to Head course of hospitalization: cooperation interventions during the
 Eye movement Injury from Vehicular whole course of
response when Accident The Patient will be able to:  Monitor VS  To note fluctuations hospitalization, the goal
called was met as evidenced by:
Verbal= 4 Ineffective Cerebral  Demonstrate stable vital  Reassess GCS  To note changes in mental
 Episodes of Tissue Perfusion signs status The Patient:
Incoherence and  Decrease in oxygen  No regression of current
Confusion in the failure to  Provide quiet  Continuous stimulation  Demonstrated stable
condition
 She doesn’t know nourish the tissues environment can increase ICP vital signs
 Increase Glasgow coma
what date it is but in the capillary  No regression of
level Scale to 15
she can tell where  To prevent increase of ICP current condition
she is and can  The Family will be able to:
 Restrict activities  Increased Glasgow
recognize some (Nanda ed. 10 page
565)  Verbalize understanding of coma Scale to 15
faces of her family  It reflects area of brain
 she could recall her condition, side effects involved, indicate safety The Family:
remote memories of medications, what to  Document changes in concerns
but not the recent watch out for vision alterations  Understand the
memories  Identify what they can do
Motor=5 condition
for her in terms of safety,  To promote venous
 Obeys some  Reported observations
assistance, physical and drainage
commands  Knew what to do
emotional support  Elevate head of bed to 30
(go on a side lying to 45 degree  Prevents venous stasis and  Complied to oral
position) further circulatory therapeutic regimen
 Behavioral changes  Promote active/passive compromise
 Irritable ROM exercises.
 There are times of
lethary &
combativeness
when in pain
 Headache
Computed
Tomography Result Dependent:  Maintains adequate filling
 Very minimal interval pressures and optimizes
regression of subdural Administer IV fluids as cardiac output needed for
hematoma at the left ordered (PNSS1L tissue perfusion
tempofrontal areas 20gtts/min)
 No pregression of  Acts as osmotic diuresis
subcortical  Mannitol 100cc q6 thereby decreasing
hemorrhagic intracranial presssure
contusions both
frontal region with  Induces mechanism of
slight progression in protection and repair and
degree of cerebral  Cerebrolysin 1amp Q8 helps in facilitating
edema formation at oxygen flow in the brain
the left
 Interval decrease in  To promote cerebral blood
previosuly noted flow and decrease
subarachnoid bleed headache
 Decrease in thickness
of scalp hematoma  Cinnarizine 25 mg tab PO  Affects intraneuronal Ca+
formation with soft TID levels and facilitates
tissue sweliing, GABA-ergic inhibitory
occipital area trasmission to decrease
severity and incidence of
VS: seizure
 BP: 90/60 mmhg  Leviteracetam 500mg tab
 T: 36.6oC degree BID
celsius/axilla
 PR: 50 bpm
(bradycardia)
 RR: 23 bpm
 O2sat: 94%