NURSING CARE PLAN

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion related to Increased

Intracranial Pressure secondary to chronic hypertension as manifested by:
S> no verbal cues
O> received lying on bed, conscious, awake and lethargic with #4 PNSS 1L @ 20
gtts/min, infusing well on right arm with remaining amount of 900 cc; with nasogastric
tube; with BP of 160/100; confused; restless and decreased reaction to light

Scientific or Theoretical Basis:

The Monroe-Kelly theorem states that any disruption of the 3 components of the
brain (CSF, brain tissues, blood) causes increase ICP. This is because blood seeps in
the ventricles leading to obstruction of the CSF passage and accumulation in the
ventricles. Increased ICP forms small and large clots in the brain that might lodge into
other arteries of the brain, which can result to cellular ischemia. Reduced arterial blood
flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue
perfusion can be transient with few or minimal consequences to the health of the patient.
Source: Marini, J. ,J. & Wheeler, A. P. Critical Care Medicine: The Essential . (3rd ed. ).
2006. Lippincott, Williams and Wilkins. Philadelphia.

Outcome Identification:
Short-term: After 8 hours of nursing interventions, the patient’s ICP will fall within normal
range of 0.15 mmHg, and will have improvement of LOC from lethargic to alert.
Long-term: After 4 days of nursing interventions, the patient maintains optimal tissue
perfusion to the brain as evidenced by normal ABGs, alert LOC and absence of
headache.

Nursing Interventions Implementation:

Intervention & Rationales

Independent:
1. Monitor quality of all pulses.
- needed for ongoing comparisons, emboli may lodge to other areas
2. Maintain optimal cardiac output.
- ensures adequate perfusion of vital organs
3. Elevate head of bed 30 to 45 degrees.
- promotes venous outflow from brain and reduce pressure
4. teach SO to avoid straining, coughing and head flat
- can increase ICP thus decreasing cerebral blood flow
5. Reorient to environment.
- may result to changes in LOC
6. Explain all procedures to the SO.
- to earn trust
7. Instruct SO to report sins and symptoms of decreased perfusion.
- to minimize possible complication

Dependent or Collaborative:
1. Assist with diagnostic testing
- may be required for accurate diagnosis
2. Administer O2 as required.
 - saturation of circulating Hemoglobin to the brain
3. Administer medication as ordered.
- to prevent further damage
4. Administer anticonvulsant as needed.
- reduces the risk of seizures
5. Perform ABG as ordered.
- maintains maximal oxygenation and ion balance

Evaluation:
Patient shifted from being lethargic to alert and no complains of headache.