NANDA Intervention Classification

Ineffective cerebral tissue perfussion r/t Cerebral Perfusion Promotion:

interruption of blood flow by cerebral Promotion of adequate perfusion and
edema; hemorrhage “Increased ICP affects limitation of complications for a patient
many patients with acute neurologic experiencing or at risk for inadequate
conditions because pathologic conditions cerebral perfusion
alter the relationship between intracranial
volume and ICP. Although elevated ICP is
most commonly associated with head
injury, it also may have be seen as a
secondary effect in other conditions, such
as brain tumors, subarrachnoid
hemorrhage, and hematomas. Increased
ICP from any cause decreases cerebral
perfusion, stimulate further swelling
(edema) and may shift brain tissue,
resulting in herniation, a dire and
frequently fatal event.”
-Brunner & Suddarth’s textbook of Medical-
Surgical Nursing, 12th Ed., Vol. 2., pg.
1864

Surveillance: Purposeful and ongoing

acquisition, interpretation and
synthesis of patient data for clinical
decision making
Cerebral Edema Management:
Limitation of secondary injury resulting
from swelling of brain tissue.
 NCP 1
Interventions Outcome Classification
Independent Interventions: Tissue perfusion: Cerebral
1. Monitored neurologic status (level of
consciousness, motor and sensory functions,
cranial nerve testing) frequently and compare
with base line.
R: Assesses trends in level of consciousness
and potential for increased intracranial
pressure and is useful in determining location,
extent, and progression /resolution of CNS
damage.
2. Monitored vital signs every two hours and
every 30mins. when on antihypertensive
taking note of hypertension or hypotension by
comparing BP readings, heart rate and rhythm
and auscultating for murmurs, and patterns
and rhythm of respirations.
R: Fluctuations in pressure may occur because
of cerebral pressure/edema in vasomotor area
of the brain Also with tissue edema, increased
intracranial pressure may occur.
Changes in rate, bradycardia, can occur
because of brain damage. dysrhythmias and
murmurs may reflect cardiac disease, which
may have precipitated cerebrovascular
accident.
Irregularities in respiration can suggest
location of cerebral insult/increasing Fluid Balance
intracranial pressure and need for further
intervention, including possible respiratory
support.
3. Reviewed laboratory values.
R: Provide information about patient’s current
status and serve as basis for comparison.
4. Evaluated pupils, noting size, shape,
equality, light reactivity.
R: Pupil reactions are regulated by the
oculomotor (III) cranial nerve and are useful in
determining whether the brainstem is intact.
Pupil size/equality is determined by balance
between parasympathetic and sympathetic
enervation. Response to light reflects
combined function of the optic (II) and
oculomotor (III) cranial nerves.
5. Monitored changes in vision and
encouraged patient to report promptly a
blurred vision or its loss when experienced.
R: Specific visual alterations reflect area of
brain involved, indicate safety concerns, and
influence choice of interventions.
combined function of the optic (II) and
oculomotor (III) cranial nerves.
5. Monitored changes in vision and
encouraged patient to report promptly a
blurred vision or its loss when experienced.
R: Specific visual alterations reflect area of
brain involved, indicate safety concerns, and
influence choice of interventions.
6. Assessed changes in speech noting for any
slurring and cognition. Neurologic Status: Cranial Sensory
R: Changes in cognition and speech content
are indicators of location/degree of cerebral
involvement and may indicate deterioration or
increased intracranial pressure.
7. Positioned with head slightly elevated and
in steady position.
R: Reduces arterial pressure by promoting
venous drainage and may improve cerebral
circulation and perfusion.
8. Assessed for the presence of pain and
taking note of its onset, location, duration,
characteristic and intensity.
R: Facilitates identification of problem and
initiation of appropriate nursing action.
9. Provided non-pharmacologic pain relieving
measures such as back rubs, cool cloth to
forehead, conversed with patient and
encouraged to do deep breathing.
R: These are measures that reduce cerebral
vascular pressure and that slow/block
sympathetic response which are effective in
relieving headache and associated
complications.
10. Maintained complete bed rest without
toilet privilege.
R: Continual stimulation or activity can
increase intracranial pressure and may
worsen headache.
11. Provided a calm and quiet environment,
and scheduled care activities to promote rest
periods.
R: Absolute rest and quiet environment may
be needed to prevent rebleediing.
12. Assessed for increasing intensity of pain
and note other nonverbal cues of pain.
R: Helps in evaluating effectiveness of
interventions.
13. Prevented straining at stool or holding
breath.
R: Valsalva maneuver increases intracranial
pressure and potentiates risk of bleeding and
may aggravate headache.
14. Monitored for twitching, increased
restlessness, irritability, headache and onset
of seizure activity.
R: Indicative of meningeal irritation, esp. in
hemorrhagic disorders. Headache and
seizures may reflect increased intracranial
pressure/cerebral injury, requiring further
evaluation and intervention.

Collaborative Interventions:
R: Indicative of meningeal irritation, esp. in
hemorrhagic disorders. Headache and
seizures may reflect increased intracranial
pressure/cerebral injury, requiring further
evaluation and intervention.

Collaborative Interventions:
1. Administered medications as indicated
(including).
a. Nicardipine
R: An antihypertensive. Preexisting/chronic
hypertension requires cautious treatment
because aggressive management increases
the risk of extension of tissue damage.
b. Mannitol
R: Also an antihypertensive.
Preexisting/chronic hypertension requires
cautious treatment because aggressive
management increases the risk of extension
of tissue damage. It also creates an osmotic
gradient that may help in the reduction of
intracerebral pressure.
c. Citicoline
R: A CNS drug spec. a peripheral vasodilator
and cerebral activator which helps in
increasing brain cell metabolism and energy
levels, and speeds up interhemispheric flow of
information. It increases alertness, improves
concentration, and enhances memory esp. for
those with s/s of cerebrovascular insufficiency.
2. Administer supplemental oxygen at
prescribed rate.
R: To correct / prevent hypoxemia, which can
cause cerebral vasodilation and increase
pressure or edema formation.
3. Prepare for surgery as appropriate.
R; May be necessary to resolve situation,
reduce neurologic symptoms and risk of
recurrent stroke.
 Evaluation

BP IER
Mean arterial pressure IER
Central venous pressure IER
Pulmonary wedge pressure IER
Peripheral pulses palpable
Orthostatic hypotension not
present
24-hour intake and output
balanced
Adventitious breath sounds not
present
Body weight stable
Ascites not present
Neck vein distention not present
Peripheral edema notpresent
Sunken eyes not present
Confusion not present
Abnormal thirst not present
Skin hydration
Moist mucous membranes
Serum electrolytes WNL
Hematocrit WNL
Urine specific gravity WNL
BP IER
Mean arterial pressure IER
Central venous pressure IER
Pulmonary wedge pressure IER
Peripheral pulses palpable
Orthostatic hypotension not
present
24-hour intake and output
balanced
Adventitious breath sounds not
present
Body weight stable
Ascites not present
Neck vein distention not present
Peripheral edema notpresent
Sunken eyes not present
Confusion not present
Abnormal thirst not present
Skin hydration
Moist mucous membranes
Serum electrolytes WNL
Hematocrit WNL
Urine specific gravity WNL
Level of Consciousness
Pupillary Assessment
Cranial Nerve Testing
Vital signs
Motor Function
Sensory Function
Tone
Cerebral Function
 NANDA Intervention Classification
Risk for Disuse SyndromeSB: Physical
immobility is a guaranteed way to 0180 Energy Management
experience a severe decline in your body Regulating energy use to treat or prevent
functions. The distinguishing disorders of fatigue and optimize function
Disuse syndrome are cardiovascular disease, Sb: Energy conservation is a process of
obesity, increased fall risk, muscle saving energy and better distributing the
weakness, depression and accelerated energy you have over the time you need
aging. to use it. If the energy you have is used
up at the beginning of the day, you have
source: http://www.articlesbase.com/health- none left for other things you may need
articles/disuse-syndrome-the-leading-cause- or want to do. Unnecessary muscle
of-premature-death-761477.html tension in certain body positions drains
energy. Good posture is the head and
back held straight and arms relaxed at
the shoulders. Poor posture uses
unnecessary energy against gravity for
hunched shoulders, curved back, and the
neck and head slightly bent forward.
Good posture, sitting or standing,
balances the weight of your head and
limbs on the bony framework so that the
force of gravity helps keep joint position.
The further you move from this position,
the more energy is required of your
muscles to pull against gravity to
maintain your position.
(http://www.anapsid.org/cnd/coping/small
ey.html)

6480 Environmental Management

Manipulation of the patient's
surroundings for therapeutic benefit,
sensory appeal, and psychological well-
being
Sb: Patients in a healthcare facility are
often fearful and uncertain about their
health, their safety, and their isolation
from normal social relationships. The
large, complex environment of a typical
hospital further contributes to the
stressful situation. Stress can cause a
person's immune system to be
suppressed, and can dampen a person's
emotional and spiritual resources,
impeding recovery and healing.
large, complex environment of a typical
hospital further contributes to the
stressful situation. Stress can cause a
person's immune system to be
suppressed, and can dampen a person's
emotional and spiritual resources,
impeding recovery and healing.
(http://www.wbdg.org/resources/therapeu
tic.php)
0200 Exercise Promotion
Facilitation of regular physical activity to
maintain or advance to a higher level of
fitness and health
Sb: Regular exercise can help protect
you from heart disease and stroke, high
blood pressure, noninsulin-dependent
diabetes, obesity, back pain,
osteoporosis, and can improve your mood
and help you to better manage stress.
For the greatest overall health benefits,
experts recommend that you do 20 to 30
minutes of aerobic activity three or more
times a week and some type of muscle
strengthening activity and stretching at
least twice a week. However, if you are
unable to do this level of activity, you can
gain substantial health benefits by
accumulating 30 minutes or more of
moderate-intensity physical activity a
day, at least five times a week.
 NCP 2
Interventions Outcomes
Independent interventions : Immobility consequences: Physiological
1. Done passive exercises
R: Active ROM helps keep muscles in
current strength and promotes
circulation. Mild activity also helps
burn unneeded calories
2. Turned to sides every 2 hrs. Risk Control:
R: To prevent formation of bed sores
3. Positioned on high fowler’s
R: Stimulates respiratory function /
lung
Immobility consequences: Psycho-Cognitive
4.Raised side rales
R: prevent falls and injury
5. Elevated feet with 1 pillow
R: To prevent formation of bed sores
6. Provided rest periods after
exercises.
R: To prevent fatigue
 Evaluation
no pressure ulcers

No decrease in muscle strength

full ROM
able to do ADLS
No occurrence of falls
monitors environmental risk factors
develops effective risk control strategies
Follows selected risk control strategies

no apathy
no negative body image
no sleep disturbances
 NANDA Intervention Classifications
Decreased Intracranial Adaptive Capacity 2540 Cerebral Edema Management
Limitation of secondary cerebral injury res
“The etiology of decreased intracranial adaptive capacity swelling of brain tissue
is failure of normal intracranial compensatory Sb: Secondary brain injury is the damage
mechanisms. The defining characteristic of this nursing after the initial trauma. Most secondary inj
diagnosis is repeated disproportionate increase in within the first 12 - 24 hours after injury, b
intracranial pressure (ICP) that can occur in response to a occur during the first 5 - 10 days after inju
variety of noxious and nonnoxious stimuli.” injury is very severe. Secondary injury resu
physiological disturbances caused by the i
- http://www.ncbi.nlm.nih.gov/pubmed/2142191 the initial trauma and from the developme
areas of cerebral ischemia and disruption o
brain barrier. Physiological disturbances, w
-Brunner & Suddarth’s textbook of Medical-Surgical the release of high levels of oxygen free ra
Nursing, 12th Ed., Vol. 2., pg. 1864 the first 24 hours postinjury and the cellula
inflammatory response and cause cerebra
hyperemia and a subsequent increase in IC
(http://calder.med.miami.edu/pointis/tbipro
over5.html)

2590 Intracranial Pressure (ICP) Monitoring

Measurement and interpretation of patient
regulate intracranial pressure
Sb: ncreased intracranial pressure can be
in cerebrospinal fluid pressure. It can also
increased pressure within the brain matter
mass (such as a tumor), bleeding into the
around the brain, or swelling within the bra
itself. An increase in intracranial pressure
medical problem. The pressure itself can d
brain or spinal cord by pressing on importa
structures and by restricting blood flow int
2590 Intracranial Pressure (ICP) Monitoring
Measurement and interpretation of patient
regulate intracranial pressure
Sb: ncreased intracranial pressure can be
in cerebrospinal fluid pressure. It can also
increased pressure within the brain matter
mass (such as a tumor), bleeding into the
around the brain, or swelling within the bra
itself. An increase in intracranial pressure
medical problem. The pressure itself can d
brain or spinal cord by pressing on importa
structures and by restricting blood flow int
itself. An increase in intracranial pressure
medical problem. The pressure itself can d
brain or spinal cord by pressing on importa
structures and by restricting blood flow int

2550 Cerebral Perfusion Promotion

Promotion of adequate perfusion and limit
complications for a patient experiencing o
inadequate cerebral perfusion
Sb: Cerebral perfusion pressure must be m
within narrow limits because too little pres
cause brain tissue to become ischemic (ha
inadequate blood flow), and too much cou
intracranial pressure (ICP).
 NCP 3
Intervention Classifications
2540 Cerebral Edema Management
Limitation of secondary cerebral injury resulting from
swelling of brain tissue
Sb: Secondary brain injury is the damage to the brain,
after the initial trauma. Most secondary injury occurs
within the first 12 - 24 hours after injury, but may also
occur during the first 5 - 10 days after injury if the initial
njury is very severe. Secondary injury results from
physiological disturbances caused by the impact and
he initial trauma and from the development of focal
areas of cerebral ischemia and disruption of the blood-
brain barrier. Physiological disturbances, which involve
he release of high levels of oxygen free radicals during
he first 24 hours postinjury and the cellular
nflammatory response and cause cerebral edema or
hyperemia and a subsequent increase in ICP.
http://calder.med.miami.edu/pointis/tbiprov/MEDICINE/
over5.html)

2590 Intracranial Pressure (ICP) Monitoring

Measurement and interpretation of patient data to
regulate intracranial pressure
Sb: ncreased intracranial pressure can be due to a rise
n cerebrospinal fluid pressure. It can also be due to
ncreased pressure within the brain matter caused by a
mass (such as a tumor), bleeding into the brain or fluid
around the brain, or swelling within the brain matter
tself. An increase in intracranial pressure is a serious
medical problem. The pressure itself can damage the
brain or spinal cord by pressing on important brain
structures and by restricting blood flow into the brain.
2590 Intracranial Pressure (ICP) Monitoring
Measurement and interpretation of patient data to
regulate intracranial pressure
Sb: ncreased intracranial pressure can be due to a rise
n cerebrospinal fluid pressure. It can also be due to
ncreased pressure within the brain matter caused by a
mass (such as a tumor), bleeding into the brain or fluid
around the brain, or swelling within the brain matter
tself. An increase in intracranial pressure is a serious
medical problem. The pressure itself can damage the
brain or spinal cord by pressing on important brain
structures and by restricting blood flow into the brain.
 tself. An increase in intracranial pressure is a serious
medical problem. The pressure itself can damage the
brain or spinal cord by pressing on important brain
structures and by restricting blood flow into the brain.

2550 Cerebral Perfusion Promotion

Promotion of adequate perfusion and limitation of
complications for a patient experiencing or at risk for
nadequate cerebral perfusion
Sb: Cerebral perfusion pressure must be maintained
within narrow limits because too little pressure could
cause brain tissue to become ischemic (having
nadequate blood flow), and too much could raise
ntracranial pressure (ICP).
 NCP 3
Interventions Outcomes
Independent Intervention: Tissue Pefusion: Cerebral
1. Elevated head of bed and maintained head/neck in
neutral position.
R: maximizes venous return
Neurologic Status
2 .Decreased extraneous stimuli, and provided
comfort measures such as quiet environment, soft
voice, back massage, and gentle touch as tolerated.
R: to reduce CNS stimulation and promote relaxation.
3. Provided rest periods between care activities and
limited duration of procedures
R: to provide a restful environment and promote
Fluid balance:
regular sleep patterns.
4. Monitored I/o and weighed as indicated.
R: to determine fluid needs and maintain hydration
and prevent fluid overload.
5. Decreased and minimized sodium intake as
necessary.
R: prevents fluid overload and increased ICP.
6. Limited and prevented activities that increase
intrathoracic or abdominal pressures such as
coughing, vomiting, straining upon bowel movement
R: these factors markedly increase ICP.
Collaborative:
1. Administered IV of 15 PNSS 1L + 10 mEq KCL as
ordered.
R: to prevent inadvertent fluid bolus or vascular
overload
2. Administered Mannitol as ordered
R: reduces intracranial pressure by increasing the
osmotic pressure of the glomerular filtrate, thereby
inhibiting reabsorption of water and electrolytes and
causing its excretion.
 Outcomes Evaluation
Tissue Pefusion: Cerebral LOC
muscle tone
pupillary action
Neurologic Status Eye Opening Response

Verbal Response
Motor Response
Level of Consciousness
Fluid balance: BP IER
Mean arterial pressure IER
Central venous pressure IER
Pulmonary wedge pressure
IER
Peripheral pulses palpable
Orthostatic hypotension not
present
24-hour intake and output
balanced
Adventitious breath sounds
not present
Body weight stable
Ascites not present
Neck vein distention not
present
Peripheral edema notpresent
Sunken eyes not present
Confusion not present
Abnormal thirst not present
Skin hydration
Moist mucous membranes
Serum electrolytes WNL
Hematocrit WNL
Urine specific gravity WNL
Other (Specify)
Evaluation