ASSESSMENT Subjective: Napapansin ko hindi na normal ang laki ng ulo ng anak ko as verbalized by the patients mother.

. Objective: Vs: T= 37.2 C PR=143 bpm RR=45 cpm HC= 41 cm (+) sleepiness (+) weakness -bulging fontanels -frontal bossing -sunsetting eyes Laboratory result decrease hemoglobin (94)

DIAGNOSIS Ineffective cerebral tissue perfusion r/t decreased blood flow as evidenced by decreased hemoglobin concentration in the blood.

PLANNING STG: After 8 hours of proper nursing interventions, the patient will demonstrate improved vital signs and absence sign of increased ICP.

INTERVENTION Independent : Monitor temperature. Administer tepid sponge bath in presence of fever.

Monitor intake and output. Weigh as indicated. Note skin turgor, status and mucous membrane. Maintain head or neck in midline or neutral position, support with small towel rolls and pillow. Avoid placing head on large pillows.

RATIONALE Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen consumption occur (especially with fever and shivering), which can further increased ICP. Useful indicator of body water, which is an integral part of tissue perfusion. Turning beds to one side compress the jugular veins and inhibits cerebral venous drainage that may cause increased ICP.

EVALUATION Goal Met

Provided rest periods between care of activities

and limit duration of procedures. Decrease extraneous stimuli and provide comfort such as back massage, quiet environment and gentle touch. Help patient avoid limit coughing, crying, vomiting, and straining at stool. Reposition of the patient slowly. Elevate the head of bed gradually to 15-30 degree as tolerated or indicated.

Continual activity can increase ICP by a producing a cumulative stimulant effect. Provides calming effects reduces adverse physiological response and promotes rest. These activities increase intrathoracic and abdominal pressure. Promotes venous drainage from head reducing cerebral congestion and edema and increase ICP.

Dependent: Administer medications as prescribed.

To increase hemoglobin concentration

ASSESSMENT Subjective: Napapansin ko hindi na normal ang laki ng ulo ng anak ko as verbalized by the patients mother. Objective: Vs: T= PR= RR= HC= 41 cm (+) sleepiness (+) weakness -bulging fontanels -frontal bossing -sunsetting eyes Laboratory result decrease hemoglobin (94)

DIAGNOSIS Ineffective cerebral tissue perfusion r/t decreased blood flow as evidenced by decreased hemoglobin concentration in the blood.

PLANNING STG: After 8 hours of proper nursing interventions, the patient will demonstrate improved vital signs and absence sign of increased ICP.

INTERVENTION Independent : Monitor temperature. Administer tepid sponge bath in presence of fever.

Monitor intake and output. Weigh as indicated. Note skin turgor, status and mucous membrane. Maintain head or neck in midline or neutral position, support with small towel rolls and pillow. Avoid placing head on large pillows.

RATIONALE Fever may reflect damage to hypothalamus. Increased metabolic needs and oxygen consumption occur (especially with fever and shivering), which can further increased ICP. Useful indicator of body water, which is an integral part of tissue perfusion. Turning beds to one side compress the jugular veins

EVALUATION Goal Met

Provided rest periods between care of activities and limit duration of procedures. Decrease extraneous stimuli and provide comfort such as back massage, quiet environment and gentle touch. Help patient avoid limit coughing, crying, vomiting, and straining at stool. Reposition of the patient slowly. Elevate the head of bed gradually to 15-30 degree as tolerated or indicated.

and inhibits cerebral venous drainage that may cause increased ICP. Continual activity can increase ICP by a producing a cumulative stimulant effect. Provides calming effects reduces adverse physiological response and promotes rest. These activities increase intrathoracic and abdominal pressure. Promotes venous drainage from head reducing cerebral congestion and edema and increase ICP.

Dependent: Administer

medications as prescribed. To increase hemoglobin concentration