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Nursing Crib Com NURSING CARE PLAN Hydrocephalus
Nursing Crib Com NURSING CARE PLAN Hydrocephalus
DIAGNOSIS Ineffective cerebral tissue perfusion related to decreased arterial or venous blood flow.
INFERENCE 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
PLANNING
INTERVENTION INDEPENDENT: Monitor temperature. Administer tepid sponge bath in presence of fever.
RATIONALE 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
EVALUATION After 8 hours of nursing interventions, the patient was able to demonstrate improved vital signs and absence of signs of increased ICP.
as verbalized by the mother. OBJECTIVE: Restlessness Irritability Changes in vital signs V/S taken as follows: T: 37.5 P: 90 R: 22
After 8 hours of nursing interventions, the patient will demonstrate improved vital signs and absence of signs of increased ICP.
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.
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.
These activities increase intrathoracic and intraabdominal pressure. Promotes venous drainage from head, reducing cerebral congestion and edema and increased ICP.
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.