Date and

Time
01/14/15
@ 7 AM

Cues

Need

Nursing diagnosis

S: Gi-butangan
siya ug tubo aron
makatabang daw
ug drain sa tubig,
ug para dili na
mudako iyang
ulo. as
verbalized by the
watcher.

A
C
T
I
V
I
T
Y

Ineffective
cerebral tissue
perfusion r/t
decreased arterial
or venous blood
flow aeb: vascular
impeding from
increase ICP
secondary to
communicating
hydrocephalus.

O:
-with CC of
seizure and
difficulty of
breathing
-with diagnosis of
severe
communicating
hydrocephalus
With head
circumference of
36.5 cm
VP shunting done

E
X
E
R
C
I
S
E
P
A
T
T
E
R
N

R: Hydrocephalus
is characterized
by an abnormal
increase in CSF
volume within the
intracranial cavity
due to an
obstruction or
malabsorption of
CSF and results
enlargement of
the head which
leads to
persistent
increase in
intracranial
pressure that can

Objective of care
After 8 hours of nursing
intervention, client will not
manifest further CNS
deterioration as evidenced
by:
a) Maintenance of level
of consciousness,
improved body
appearance.
b) Vital signs
maintained at normal
range:
T: 36.7-37.5*C
CR: 120-160 bpm
RR: 40-60 cpm
c) Watchers
verbalization of the
childs improvement
of alertness, feeding
and cry.

Nursing intervention

evalua

INDEPENDENT:
1.Establish rapport an
d good working
relationship with the
watcher.
R: To gain trust and
cooperation.

01/14/15 @

2.Monitor vital signs

noting:
a. Heart and rhythm,
auscultated for
murmurs.
R: Changes in rate,
especially in
bradychardia, can
occur because of
brain damage.
b. Respirations
R: Irregularities can
suggest location of
cerebral insult or
increased intracranial
pressure
3. Evaluate pupils,
noting size, shape,
and equality, and light

Goal partial

After 8 hour
nursing inte
client have
manifested
CNS deterio
evidenced b

a) Child
obse
be w
is alw
aslee

b) VS:
T-37
CR-1
RR-3

c) Med
nam
miss
na s
mud
pare
dati u
kuso

last Jan. 3, 2015

CT scan results:
(+) head
circumference
large for age
(+) multiple
cerebral &
intraventricular
bleed
With RLS & GCS
of 1/12
With observed
generalized weak
appearance
Weak cry
(+) bulging of the
soft spot on the
head.
VS of:
T: 37.2*C
CR: 156 bpm
RR: 34 cpm

damage brain
tissue and may
cause
developmental
delays.

reactivity.
R: Pupil reactions are
regulated by the
Oculomotor (III)
cranial nerve are
useful in determining
whether the brainstem
is intact.
4. Position head
slightly elevated (1530 degrees)and in
neutral position.
R: Reduces arterial
pressure by promoting
venous drainage and
may improve cerebral
circulation and
perfusion.
5. Maintain bed rest
and provided a quiet
environment.
R: Continual
stimulation can
increase Intra-cranial
pressure and cerebral
edema.
COLLABORATIVE:
6. Administer
supplemental oxygen

iyang
As v
by th
watc

as indicated
R: Reduces
hypoxemia
7. Administer
acetazolamide specific
dose, frequency, route
as prescribed by the
physician.
R: Drug action:
Acetazolamide was
known to decrease
production of
cerebrospinal fluid that
would decrease intra
cranial pressure.