Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective cues: After 8 Independent: After 8 hours of

hours of nursing intervention,
Ineffective
Restlessne nursing Monitor Fever may the patient was able
ss
cerebral tissue interventio temperature reflect to demonstrate
Irritability perfusion r/t n, the Administer TSB damage to improved vital sign
Changes in decreased arterial patient will when febrile. hypothalamu and absence of INCP.
vital signs or venous blood demonstrat s, increased
flo e improved oxygen
vital signs consumption
and occur which
absence of can further
increased increased
ICP ICP.

Useful
Monitor Intake indicators of
and Output. body water,
which is an
integral part
of tissue
perfusion.

Maintain head Turning bed

in neutral to one side
position. compresses
the jugular
vein that
may cause
increased
ICP.
Provide rest
period. Continual
 activity can
increase ICP

Elevate the Promoted

head of bed venous
gradually to 15- drainage
30 degrees as from head,
tolerated reducing
cerebral
congestion
and
increased
ICP .

Administer It has
diuretics as diuretic
indicated. effect.
Provide
supplemental Reduces
oxygen hypoxemia,
which may
increase
cerebral
vasodilation
and blood
volume.
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective cues: Imbalanced After 8 Provide a Pleasing After 8
hours of
Inability to ingest Nutrition: Less hours of pleasant atmosphere nursing
foods Than Body nursing environment. helps in intervention
, Goal met
Unwillingness to Requirements intervention, decreasing stress the patient
was able to
eat the patient and is more consume
Vomiting will consume favorable to eat. the serve
meal.
Lethargic the serve
meal. Promote Aids in
proper swallowing and
positioning reduces
while eating aspiration with
eating.

Offer liquid to produce

energy weight gain and
supplements reduce falls in
frail

Provide good Oral hygiene

has a positive
 oral hygiene effect on
and dentition appetite and on
the taste of food.

Nutritional
Consider the
support may be
possible
recommended
need for
for patients who
enteral or
are unable to
parenteral
maintain
nutritional
nutritional intake
support
by the oral route