Ineffective Tissue Perfusion related to increased intracranial pressure
Definition
Meningitis is an inflammation of the lining of the encephalon (arachnoid in addition to piamater). Bacteria in addition to viruses are the leading displace of meningitis.
Purpose
Expected results:
Action Plan
Impaired Tissue Perfusion Nursing Interventions for Meningitis
1. Patient's full bed balance alongside supine sleeping rate without a pillow.
Rationale: Changes inwards intracranial pressure level volition move able to mislead the opportunity for encephalon herniation.
2. Monitor signs of neurological condition alongside a GCS.
Rational: To trim down farther encephalon damage.
3. Monitor vital signs such every bit BP, pulse, temperature, respiration, in addition to caution inwards systolic hypertension.
Rational: In the normal soil of autoregulation to keep a soil of altered systemic blood pressure level fluctuations. Autoreguler failure would atomic number 82 to cerebral vascular harm tin strength out move manifested yesteryear an increment inwards systolic in addition to diastolic pressure level followed yesteryear a decline. While the increment inwards temperature tin strength out push clit the shape of infection.
4. Monitor intake in addition to output.
Rational: Hyperthermia tin strength out atomic number 82 to increased IWL in addition to increased opportunity of dehydration, specially inwards patients who are non aware, nausea which decreases oral intake.
5. Help the patient to bound vomiting, coughing. Instruct patient to exhale when moving or turning inwards bed.
Rationale: This action tin strength out increment intracranial pressure level in addition to intra-abdominal. Exhale when moving or changing positions to protect themselves from the effects of Valsalva.
6. Collaboration
Give intravenous fluids alongside strict attention.
Rationale: Minimizing the burden of vascular in addition to fluctuations inwards intracranial pressure, fluid in addition to fluid vetriksi tin strength out trim down cerebral edema.
7. Monitor blood gas analysis of oxygen delivery when needed.
Rational: The possibility of acidosis accompanied yesteryear the loose of oxygen at the cellular score may atomic number 82 to ischemic cerebral.
8. Provide appropriate handling advice doctors
Rational: The therapy is given to decrease capillary permeability, decrease cerebral edema, in addition to lower metabolic cells / consumption in addition to seizures. Sumber http://nanda-nursinginterventions.blogspot.com/
Definition
Meningitis is an inflammation of the lining of the encephalon (arachnoid in addition to piamater). Bacteria in addition to viruses are the leading displace of meningitis.
Purpose
- The patient returned to the soil of the neurological condition earlier the illness
- Increased patient awareness in addition to sensory function
Expected results:
- Vital signs inside normal limits
- Head hurting was reduced
- Increased awareness
- An increment inwards cognitive or loss in addition to no signs of increased intracranial pressure.
Action Plan
Impaired Tissue Perfusion Nursing Interventions for Meningitis
1. Patient's full bed balance alongside supine sleeping rate without a pillow.
Rationale: Changes inwards intracranial pressure level volition move able to mislead the opportunity for encephalon herniation.
2. Monitor signs of neurological condition alongside a GCS.
Rational: To trim down farther encephalon damage.
3. Monitor vital signs such every bit BP, pulse, temperature, respiration, in addition to caution inwards systolic hypertension.
Rational: In the normal soil of autoregulation to keep a soil of altered systemic blood pressure level fluctuations. Autoreguler failure would atomic number 82 to cerebral vascular harm tin strength out move manifested yesteryear an increment inwards systolic in addition to diastolic pressure level followed yesteryear a decline. While the increment inwards temperature tin strength out push clit the shape of infection.
4. Monitor intake in addition to output.
Rational: Hyperthermia tin strength out atomic number 82 to increased IWL in addition to increased opportunity of dehydration, specially inwards patients who are non aware, nausea which decreases oral intake.
5. Help the patient to bound vomiting, coughing. Instruct patient to exhale when moving or turning inwards bed.
Rationale: This action tin strength out increment intracranial pressure level in addition to intra-abdominal. Exhale when moving or changing positions to protect themselves from the effects of Valsalva.
6. Collaboration
Give intravenous fluids alongside strict attention.
Rationale: Minimizing the burden of vascular in addition to fluctuations inwards intracranial pressure, fluid in addition to fluid vetriksi tin strength out trim down cerebral edema.
7. Monitor blood gas analysis of oxygen delivery when needed.
Rational: The possibility of acidosis accompanied yesteryear the loose of oxygen at the cellular score may atomic number 82 to ischemic cerebral.
8. Provide appropriate handling advice doctors
Rational: The therapy is given to decrease capillary permeability, decrease cerebral edema, in addition to lower metabolic cells / consumption in addition to seizures. Sumber http://nanda-nursinginterventions.blogspot.com/