ASSESSMEN

T
Not
applicable

NURSING DIAGNOSIS
WITH RATIONALE
Risk for Ineffective
Cerebral Tissue
Perfusion related to
cerebral edema and
increased
intracranial pressure
related to increased
ICP
Rationale:
The invading
organism triggers an
inflammatory
response in the
meninges. In an
attempt to ward off
the invasion,
neutrophils gather in
the area and
produce an exudate
in the subarachnoid
space. The exudates
irritate the
meninges, disrupting
their cell membranes
and cause edema.
Cerebral edema can
cause increased
intracranial pressure
resulting to
decreased cerebral
perfusion.

OBJECTIVE
S
After 5
days of
intensive
nursing
interventio
ns, the
client will
maintain
good
cerebral
tissue
perfusion
as
evidenced
by good
neurologic
al status
with GCS
of 15,
absence of
signs of
increased
intracrania
l pressure,
and stable
vital signs.

NURSING
INTERVENTIONS
Assessment:
Monitor neurologic
status frequently and
compare with
baseline.

RATIONALE FOR
INTERVENTIONS
Assesses trends
and potential for
increased ICP.

Monitor vital signs

especially :
BP, note continuing
systolic hypertension
and widening of pulse
pressure.

Heart rate and

rhythm.

Normally, the
autoregulation
function of the
brain maintains a
constant cerebral
blood flow despite
fluctuations in
systemic BP. Loss of
autoregulation may
follow local or
diffuse
cerebrovascular
damage.
An elevating
systolic BP
accompanied by
decreasing diastolic
BP (widening pulse
pressure), is an
ominous sign of
increased ICP
accompanied by
decreased LOC.
Bradycardia and

OUTCOME CRITERIA
Within 5 days of
intensive nursing care
of the patient, the
client was able to
Maintain good
cerebral tissue
perfusion as
evidenced by
absence of signs of
increased ICP:
changes in LOC such
as slowing of speech
and delayed verbal
response,
restlessness,
confusion
Absence of vital signs
irregularities:
slow bounding pulse
pulse pressure or >30
irregular breathing
(CheyneStrokes
breathing)
present:
bronchovesicular
respiration
Increased awareness

References:
LWBK278-4147GC02_118-159.qxd
03/02/2009 03:33
PM Page 144 Aptara
Inc.
(file:///D:/My
%20Documents/MEN
INGITIS_LWBK2784147G-C02_144145.pdf)

Note respirations,
noting patterns and
rhythm.

Investigate increasing
restlessness,
moaning, and
guarding behaviors.

Critical Care Nursing

Handbook
By William Porter
p.52

Assess for nuchal

rigidity, twitching,
increased
restlessness, and
irritability.

Assess position or
movement of the
eyes, noting whether
they are in
midposition or
deviated sideward or
downward. Note loss
of dolls eyes
(oculocephalic reflex).

dysrhythmias may
develop reflecting
the injury in the
brain.
Irregularities can
suggest increasing
ICP and need for
further intervention
These nonverbal
cues may indicate
increasing ICP or
pain. Unrelieved
pain can potentiate
increased ICP.
Indicative of
meningeal
irritation, which
may occur because
of infection.

Position and
movement of the
eyes help localize
the area of brain
involvement. An
early sign of
increased ICP is
impaired abduction
of eyes, indicating
pressure/injury to

BP:100/70
HR:102bpm
Temp:36.5
O2 Saturation:99%
Maintain good
oxygen saturation
evidenced by
O2 saturation = 98100%

the fifth cranial

nerve. Loss of dolls
eyes indicates
deterioration in
brainstem function
and poor prognosis.
Independent:
Regulate
environmental
temperature as
indicated by: limiting
use of blankets;
administering tepid
sponge bath in
presence of fever, etc.

Maintain head or neck

in midline or neutral
position, support with
small towel rolls and
pillows.

Decrease extraneous
stimuli and provide
comfort measures
(quiet room, soft
voice, gentle touch).

Fever may reflect

damage to the
hypothalamus.
Increased
metabolic needs
and oxygen
consumption occur
which can further
increase ICP.
Turning head to one
side compresses
the jugular veins
and inhibits
cerebral venous
drainage, thereby
increasing ICP.
Provides calming
effect which
reduces adverse
physiologic

Reposition client
slowly; prevent client
from bending knees
and pushing heels
against mattress to
move up in bed.
Elevate head of bed
gradually to 20- 30
degrees as tolerated
or indicated. Avoid hip
flexion greater than
90 degrees.
Dependent:
Monitor ABGs and
pulse oximetry.

Administer
supplemental oxygen
to maintain oxygen
saturation >94% as
indicated.

Assist in Intubation as
indicated
Administer
medications as
indicated:

response and
promotes rest to
maintain or lower
ICP.
These activities
increase intrathoracic and
intraabdominal
pressures, which
can increase ICP.
Promotes venous
drainage from
head, thereby
reducing cerebral
congestion and
edema and risk of
increased ICP.
Determines
presence of
hypoxia and
indicates therapy
needs.
Reduces
hypoxemia, which
is known to
increase cerebral
vasodilation and
blood volume,
elevating ICP.

Diuretics:

To provide a patent
airway and increase
oxygenation

Anticonvulsant:
phenytoin (Dilantin)
Antipyretics:

To reduce cerebral
edema.
Reduces and
control fever and
headache.
To prevent seizure
activity associated
with increased ICP.

ASSESSMEN
T
Objective
cues:
BP:130/70
HR:
140bpm
RR:28
Temp: 38.5
02
Saturation
:98%
WBC
20.0x10^9
/L
Segmenter
s 90 %

NURSING DIAGNOSIS
WITH RATIONALE
2. Hyperthermia may
be related to direct
effect of circulating
endotoxins on the
hypothalamus,
altering temperature
regulation.
As evidenced by:
1. Increase in
body
temperature
higher than
normal range
(38.5 C)
2. Increased
respiratory
rate,
tachycardia
3. Flushed skin,
warm to touch

OBJECTIVE
S
After 2
hours of
nursing
interventio
ns, the
client will
Demonstra
te
temperatu
re within
normal
range

NURSING
INTERVENTIONS
INDEPENDENT
1. Monitor Client
temperature
(degree and
pattern), note
shaking chills/
profuse
diaphoresis.

RATIONALE FOR
INTERVENTIONS
Temperature of 38
41 C) suggests
acute infectious
disease process.
Fever pattern may
aid in diagnosis,
example sustained
or continuous fever
curves lasting more
than 24 hours
suggest
pneumococcal
pneumonia,
remittent fever
(varying only a few
degrees in either
direction) reflect
pulmonary
infections;
intermittent curves
or fever that

OUTCOME CRITERIA
Within the 2 hour care
of the patient, the
client was able to

Demonstrate
temperature
within normal
range (36.4 C)

2. Provide tepid
sponge bath,
avoid use of
alcohol

3. Monitor
environmental
temperature,
limit/add bed
linens as
indicated
COLLABORATIVE
1. Administer
antipyretics
(Paracetamol
300mg IV)

returns normal
once in 24 hour
period suggest
septic episodes.
May help reduce
fever. Note: Use of
alcohol/ ice water
chips may cause
chills, actually
elevating
temperature.
Room temperature/
number of blankets
should be altered to
maintain nearnormal body
temperature.
Used to reduce
fever by its central
action on the
hypothalamus;
fever should be
controlled in clients
who are
neutropenic or
asplenic.