Problem #1: Ineffective Cerebral Tissue Perfusion

General Goal: Patient will have effective cerebral tissue perfusion

Predicted Behavioral Outcome Objective: Patient will show
effective tissue perfusion as evidenced by stable vitals, reactive
pupils, and no abnormal seizure activity during shift.

Nursing Interventions:
1. review ABG, BUN, Creat, and electrolytes, Hgb and Hct
2. check respirations and absence of work of breathing
3. record BP changes (drop of 20 sys or 10 dias)
4. examine GI function
5. use pulse ox to monitor pulse and sat levels
6. Monitor urine output
7. assess neuro status
8. evaluate eye opening

Patient Responses:
1. ABG: 7.48 (uncomp metabolic alk), BUN: 24 -> 19, Creat: 1.1 ->
0.7, Electrolytes: Na @ 135 / K @ 3.8 / Cl @ 97 (low, but up from
95) / Ca @ 1.26 (low, down from 9.3) / Mg @ 2.2, Hgb: 11.5 (low,
down from 13.3), Hct: 33.5 (low, down from 39.0)
2. respers low (less than 12/min for majority of shift)
3. Sys drop from 153-139 after 10 mcg hydralazine administered IV
4. bowel sounds present x 4, no signs of slowed peristalsis
5. pulse range during shift: 66-69 bpm, sat at 98-100%
6. urine output low, less than 200mL in a 6 hour shift (175 mL)
7. patient had abnormal neuro presentations and was sedated to a -
2 on tge RASS scale
8. eye opening to pain -> eye opening to voice

Goal met during shift. Some abnormal labs present, but patient
did not show any S/S of poor perfusion during shift.
Problem #2: Risk for increased ICP
General Goal: Patient will not suffer symptoms of increased ICP
Predicted Behavioral Outcome Objective: Patient will not show
signs of increased ICP as evidenced by stable vitals, normal eye-
light reactions, absence of vomiting and absence of seizure activity
during shift.

Nursing Interventions:
1. asses for and report symptoms of IICP
2. assess pupils for appropriate reactions
3. asses for nausea, vomiting, and papilledema
4. elevate head of bead to 30 degrees
5. assess for and report S/S of seizure activity
6. administer anticonvulsants as prescribed
7. maintain a patent airway to reduce chance cerebral hypoxia
8. observe for and control conditions that can cause agitation

Patient Responses:
1. no outstanding symptoms noted
2. pupils sluggish but PERRLA
3. no nausea, vomiting, or papilledema present
4. tolerated well, head of bed continuously elevated at 30 degrees
5. no S/S of seizure activity
6. anticonvulsants administered prior to shift
7. vent and ett in place, patent airway maintained
8. patient sedated with a RASS of -2 to prevent agitation

Goal met during shift. Although his ICP was probably increased
due to the ICH and midline shift, no excess ICP was added
during shift.
Problem #3: Ineffective Airway Clearance
General Goal: Patient will have effective ventilation.
Predicted Behavioral Outcome Objective: The patient will
maintain patent airway as evidenced by the absence of adventitious
breath sounds and no signs or symptoms of respiratory distress
such as restlessness or anxiety.

Nursing Interventions:
1. Assess and document breath sounds in all lung fields at least hr.
and with any change in position. Note quality and presence of
adventitious breath sounds
2. Assess SPO2
3. Monitor patient closely for respiratory distress (restlessness and
anxiety)
4. Elevate HOB 30 degrees
5. Suction only as needed
6. Monitor patients hydration status
7. Turn patient Q 2hrs. to promote ventilation
8. Monitor chest x-ray

Patient Responses:
1. Unlabored but diminished breath sounds bilaterally, crackles in
base bilaterally
2. SpO2 remained 98 and above entire shift
3. No S/S of respiratory distress
4. Patient tolerated well
5. Suctioned intermittently throughout shift, thick greenish-tan
secretions noted.
6. Good turgor, urine yellow and clear
7. Patient tolerated well
8. Lung fields clear initially, nodule spotted and written for follow
up.

Goal met during shift. Sats remained at 98%-100% during shift,

suctioning was needed infrequently.
Problem #4: Ineffective Thermoregulation
General Goal: patient will remain normothermic during shift
Predicted Behavioral Outcome Objective: Patient will maintain a
temperature within normal range (>96.6 - <100.4) on day of care
Nursing Interventions:
1. Monitor patient’s temperature at frequent intervals
2. administer antipyretic as prescribed
3. monitor vital signs
4. monitor white blood cell count
5. cooling blanket may be prescribed
6. monitor labs
7. monitor I&O

Patient Responses:
1. temp recorded q2 hrs via indwelling catheter
2. 650 mg acetaminophen administered > dropped from 101.5 to
100.3
3. high core temp (indwelling catheter), high blood pressure
4. WBC within normal range
5. no cooling blanket needed
6. labs show high albumin trend > urine retention d/t higher temp
7. intake restricted, output limited during shift

Goal partially met during shift. Patient temperature at one

point reached 101.5. Cover nurse alerted, and anti-pyretics
administered w/ instructor.
Problem #5: Impaired Urinary Elimination
General Goal: Patient will have effective cerebral tissue perfusion
Predicted Behavioral Outcome Objective: Patient will show
effective tissue perfusion as evidenced by stable vitals, reactive
pupils, and no abnormal seizure activity during shift.

Nursing Interventions:
1. Monitor urine output
2. review drug regimen (narcotics)
3. encourage adequate fluid intake
4. catheterize as indicated
5. Monitor BUN, Creat, and WBC count, and Albumin
6. palpate bladder for distension

Patient Responses:
1. urine output for shift @ 175 mL
2. pt on IV fentanyl, can reduce urinary output
3. pt on fluid restriction
4. pt has indwelling catherter inserted
5. BUN @ 19, Creat @ 0.7, WBC @ 11.1, Albumin @ 8.5 (high, up
from 4.5)
6. bladder palpated, somewhat firm. No excess urine voided while
massaged.

Goal not met during shift. Patient still at risk for impaired
urinary elimination.
Problem #6: Imbalanced nutrition: Less Than Body Requirements
General Goal: Patient will have adequate nutrition
Predicted Behavioral Outcome Objective: Patient will not show
S/S of inadequate nutrition and will remain the same weight, if not
gain.

Nursing Interventions:
1. Weigh patient daily
2. Monitor protein and albumin levels
3. Record and track I&O
4. Monitor appearance of skin
5. observe/document any areas of skin breakdown (degenerative
nitrogen state)
6. assess for residual on continuous tube feed q4 hrs

Patient Responses:
1. Patient weight 64 KG (up from 63 KG)
2. total protein: 6.6 (down from 7.1), albumin: 8.5 (up from 4.5)
3. Pt on fluid restriction, 40 mL flush, continuous tube feed, output
at 175 after 6 hours
4. skin appeared to be normal, no flaking/dryness/excessive
redness
5. no skin breakdown noted
6. residual @ 50 mL

Goal met during shift.

Problem #7: Risk for unilateral neglect
General Goal: Pt will show lessening of S/S of unilateral neglect
Predicted Behavioral Outcome Objective: Patient will
demonstrate beginning of adaptation to unilateral neglect during
shift

Nursing Interventions:
1. Use drawsheet to move patient to avoid skin tearing
2. Support neglected side/extremities to avoid contractures
3. Assess sensation
4. Assess mobility
5. ROM exercises on affected side during shift
6. encourage patient and family to express feelings over patient level
of functioning

Patient Responses:
1. patient tolerated well, no skin tearing or shearing
2. LLE propped on pillow, ULE propped on pillow
3. sensation weak on affected side, patient insists he feels it
4. mobility on affected side weak
5. ROM exercise on left leg and arm tolerated well
6. family expressed concern over sedation and living conditions,
answered questions and referred them to social work for further
answers

Goal met during shift.