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Nursing Management - Ineffective Cerebral Tissue Perfusion related to Hydrocephalus

Nursing Diagnosis for Hydrocephalus
Ineffective Cerebral Tissue Perfusion related to increased volume of cerebrospinal fluid.
NOC : circulation status
NOC – Expected outcomes:
1. Indicate the status of the circulation is characterized by the following indicators:
  • Systolic and diastolic blood pressure within normal range
  • No major vein noisy
2. Demonstrated cognitive abilities, characterized by the indicator:
  • Communicate clearly and in accordance with the age and ability
  • Show attention, concentration and orientation
  • Demonstrated long-term memory and the current
  • Process information
  • Make the right decision
Hydrocephalus – Ineffective Cerebral Tissue Perfusion – NIC Interventions
1. Monitor the following matters:
  • Vital signs
  • Headache
  • Level of awareness and orientation
  • Inistagmus diplopia, blurred vision, visual acuity
2. Monitoring of ICT:
  • ICT monitoring and neurological response of the patient care activities
  • Monitor tissue perfusion pressure
  • Note the change in the patient in response to stimulus
4. Management of peripheral sensation
  • Monitor the presence of paresthesias: numbness or tingling
  • Monitor the status of fluid intake and output including
5. Collaborative activity
  • Keep the thermodynamic parameters within the range recommended
  • Give the drugs to increase intravascular volume, as requested
  • Give a drug which causes hypertension to maintain cerebral perfusion pressure according to demand
  • Elevate the head of the bed 0 to 45 degrees, depending on the patient’s condition and medical demand
  • Give loap and osmotic diuretics, according to demand.
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