ASSESSMENT NURSING OUTCOME INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Risk for Short term: Independent: Goal met after
Subjective: ineffective After 8hrs of each nursing
The baby cries picked cerebral nursing Monitor temperature Fever may reflect interventions the
up or rocked by her tissue intervention the and vital signs. damage to patient’s
mother and quiets perfusion: client will damage to condition
when allowed to lie Risk Factor: maintain level of hypothalamus. improved with
still. hypervolemia consciousness normal vital
of cerebral at normal level, Maintain head or Turning bed to one signs,
Objective: ventricles. improved neck in midline or in side compresses physiological
 Baby has a big appearance and neutral position, the jugular veins state and no
head. stable vital support with small and inhibits signs of
 Occipito-frontal signs. towel rolls and cerebral venous intracranial
circumference – pillows. drainage that may pressure.
49.5cm Long Term: Avoid placing head cause increased
 Chest After 24hrs of on large pillows. ICP.
circumference – nursing
7.3cm examination the Help avoid crying Crying increases
 Abdominal patient will and straining. intrathoracic and
circumference – obtain normal intra-abdominal
33cm vital signs with pressure.
 APGAR score 6 the absence
Maintain quiet Calming effect
Vital signs: from the signs
environment, gentle reduce adverse
 Temp. – 35.0C of intracranial
touch and comfort physiological
 Heart Rate – pressure. The
measures. response and will
90 bpm client will no
 RR – 10 longer be able promote proper
breaths per to manifest rest.
minute further CNS
 Irritable and deterioration.
Promote venous
lethargic at Elevate patient’s
 times head as tolerated. drainage from
Physical examination: head and
 Anterior and increased ICP.
posterior Dependent:
fontanels had
widened. Administer
 Dilation of medications as
scalp veins ordered by the
and hypertonic doctor:
lower Used to treat a
extremities Cloxacillin
wide variety of
 face was bacterial
broadened infections. It works
with frontal by stopping the
protrusion and growth of bacteria.
with a “setting
sun” sign Used to treat
Systemic examination Gentamycin serious bacterial
of CNS: infections in many
 lethargic different parts of
 poor sucking the body.
reflex
 hypertonic Infusion pump with
Used to deliver
muscle tone mainline IVF of D5
nutrients or
CT scan: IMB 500cc x
medications.
 hydrocephalus 40cc/hour
 restriction of
brain cortical
growth due to
fluid Treat patient via:
compression To help drain the
Ventricular extra CSF from
peritoneal shunting your brain, a VP
shunt will be
placed into your
head.