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Ineffective Tissue Perfusion

The patient was experiencing dizziness, blurred vision, decreased consciousness, right-sided weakness, nausea, vomiting, restlessness, slurred speech, and increased intracranial pressure. The nursing diagnosis was ineffective cerebral tissue perfusion related to brain injury. Short term goals included adequate perfusion and circulation after 8 hours of interventions. Long term goals were to improve the patient's Glasgow Coma Scale from 11 to 15 after 3 days. Interventions included elevating the head of bed, maintaining neutral neck position, using side rails, instructing on avoiding strenuous actions, monitoring ventilation, and administering oxygen.

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Em Castillo
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6K views1 page

Ineffective Tissue Perfusion

The patient was experiencing dizziness, blurred vision, decreased consciousness, right-sided weakness, nausea, vomiting, restlessness, slurred speech, and increased intracranial pressure. The nursing diagnosis was ineffective cerebral tissue perfusion related to brain injury. Short term goals included adequate perfusion and circulation after 8 hours of interventions. Long term goals were to improve the patient's Glasgow Coma Scale from 11 to 15 after 3 days. Interventions included elevating the head of bed, maintaining neutral neck position, using side rails, instructing on avoiding strenuous actions, monitoring ventilation, and administering oxygen.

Uploaded by

Em Castillo
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment Subjective: Nahihilo ako tapos nanglalabo minsan ang paningin ko . As patient verbalized.

Objective: - decrease level of consciousness (GCS = 11) E- 3 V- 4 M- 4 -dizziness -right sided weakness -nausea and vomiting -restless -slurred speech -increased ICP

Nursing Diagnosis Ineffective cerebral tissue perfusion related to brain injury

Planning Short term: After 8 hours of nursing interventions the client will receive adequate perfusion and circulation of well-oxygenated blood. Long term: After 3 days of nursing interventions, the client will improve his GCS from 11 to 15

Intervention -elevate head of bed and maintain head and neck in neutral position

Rationale -to promote circulation and venous drainage and improve cerebral perfusion and circulation -patient is at risk of falls due to body weakness -to prevent further damage to the brain cells

Evaluation Goal met

-maintain side rails up

- instruct patient to avoid any strenuous action that may cause further increase in intracranial pressure such as coughing and sneezing -monitor the regulation of the mechanical ventilator -administer oxygen as prescribed

-to ensure adequate air with oxygen are compressed in the lungs -to prevent hypoxemia and to increase blood oxygenation

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