Nursing Care Plan

Patient’s Name: Age: 27 years old Sex: Male Address:

Pathophysiologic/ Nursing
Assessment Cues Nursing Diagnosis Desired Outcome Rationale Evaluation
Schematic Diagram Intervention

Subjective Cues: Ineffective After 8 hours of After 8 hours of

“Gasakit akon ulo cerebral tissue Predisposing Factors: Nursing Nursing
kag gakalipungan perfusion related MALE Intervention, the Intervention, the
ko. Ga blur palan- to cerebral edema 27 years old patient and patient and
awan ko” as as evidenced by significant other significant other
verbalized by increased Precipitating Factors:
will be able to: was able to:
patient intracranial - hereditary genetic
Dependent
pressure and factors
Interventions:
Objective Cues: increased CSF - cancer on other parts
1. Demonstrate 1. GOAL MET. The
- fainting protein of the body
stable vital signs 1. Administer 1. Brain tumors can patient demonstrates
- recurrent headache - exposure to ionizing
radiations and absence of signs antiepileptic drugs put pressure on stable vital signs
and vomiting
- stressful of increased ICP. neurons within the and absence of signs
- increased of Definition:
respiratory rate Inadequate tissue environment brain and cause of increased ICP.
- decreased in motor perfusion happens 2. Maintain usual or electrical activity to
function when one or more improved LOC, overreact. Patients 2. GOAL MET. The
- CT scan of the organs beginning cognition, and are at high risk for patient was able to
brain visualizes to fail due to Fast Growing Tumor motor and sensory seizures. maintain usual or
presence of tumor disturbances upon function Antiepileptic drugs improved LOC,
and cerebral edema Increased ICP
reaching an organ increase the seizure cognition, and
- lumbar puncture threshold. motor and sensory
Reduction in volume
reveals increased function
Intracranial of blood and CSF
pressure, increased 3. Show signs of 2. Administer other 2. Chemotherapy GOAL MET. The
CSF protein Source: Displacement of CDF adequate cerebral medication therapy and/or radiation patient was able to
- CBC results https:// perfusion and as ordered may be given to show signs of
in to Spinal cord and
showed increased in healthfully.com/ oxygenation. (Chemotherapy shrink the tumor. adequate cerebral
WBC health/ Subarachnoid space
Corticosteroids Corticosteroids are perfusion and
- V/S taken as #ixzz1nMguNJUg Antiemetics) given to decrease oxygenation.
follows: inflammation
T: 36.8
Impairment of venous around the tumor.
PR: 79
drainage Antiemetics are
RR: 23
given to decrease
BP: 130/80
Long Term: nausea and prevent
1. After 4 days of vomiting if possible 1. GOAL MET.
Venous congestion nursing The patient was able
and papileedema interventions the to demonstrate
patient will be able 3. Administer 3. To restore and stable ICP AEB
to demonstrate oxygen maintain blood normalization of
stable ICP AEB oxygen level pressure
S/S
normalization of
- recurrent headache
pressure
esp early in the
morning
- seizure
- Nausea or vomiting
- Fatigue
- Drowsiness Independent
- Sleep problems Interventions:
- Memory problems
- Changes in ability to
1. Place the patient 1. Side rails should
walk or perform daily
activities in seizure be padded to
- Altered perception precautions prevent injury;
of touch or pressure, suction should be
arm or leg weakness available in case of
on 1 side of the body aspiration during a
- Pressure or headache seizure.
near the tumor

2. Neurological
2. Frequent neuro changes related to
checks (q1-2h) increasing ICP may
Nursing Diagnosis
Ineffective cerebral be subtle or may
tissue perfusion occur rapidly.
related to increased Frequent detailed
intracranial pressure neuro checks allow
as evidenced by changes to be
cerebral edema and recognized quickly
increased CSF protein so that interventions
can be initiated.

3.
3. Perform
interventions to
minimize ICP: - HOB <30 will be
- Maintain HOB increased blood
30-45° flow to brain will
result to increased
ICP; HOB> 45
increased
intrathoracic
pressure →
 decreased venous
outflow from brain
→ increased ICP

- Decrease stimuli - Agitation or

stress can
cause
increased ICP

4. Monitor V/S,
MIO and daily 4. To note response
weight and record to activities