CUES EXPLANATION OF GOALS AND INTERVENTION RATIONALE EVALUATION ACTUAL EVALUATION

THE PROBLEM OBJECTIVES CRITERIA

SUBJECTIVE: Blood is a STO: DIAGNOSTICS: FULLY MET
connective tissue After 8 hours of  If the patient
composed of a liquid appropriate nursing 1. Monitored respirations and  Cardiac pump maintains an alert
extracellular matrix interventions, the absence of work of malfunction and/or level of
OBJECTIVE: called blood plasma patient will be able breathing. ischemic pain may result consciousness
 Altered level of that dissolves and to: in respiratory distress. throughout the
consciousness suspends various a) Maintain usual Nevertheless, abrupt or shift
 Confusion cells and cell or improved continuous dyspnea  If the patient was
 Decreased GCS fragments. Blood level of may signify kept reoriented to
score transports oxygen consciousness thromboembolic time, place, and
 Language deficits from the lungs and b) Verbalize pulmonary person.
 As of August 18, nutrients from the reorientation to complications.  If the patient
2017 gastrointestinal time, place, and maintains a warm
CT-scan result shows tract. The oxygen person. 2. Checked rapid changes or  Electrolyte/acid-base and dry skin
significant regression and nutrients c) Maintain continued shifts in mental variations, hypoxia, and during the shift.
of bilateral subdural subsequently diffuse maximum tissue status. systemic emboli  If the patient
hematomaoverlying from the blood into perfusion to vital influence cerebral displays tolerance
both cerebral the interstitial fluid organs, as perfusion. In addition, it during activities.
hemisphere as and then into the evidenced by is directly related to  If the patient
described, with body cells. warm and dry cardiac output. maintains usual or
associated mass Circulating blood skin. normal sensations
effect. helps maintain and motor
--recent note of the homeostasis of all LTO: activity.
following: acute left body fluids. Blood After 4 days of 3. Monitored oxygen  Pulse oximetry is a
temporal epidural helps adjust body appropriate nursing saturation useful tool to detect PARTIALLY MET
hematoma, temperature interventions, the changes in oxygenation.  If the patient
pneumocephalus, through the heat patient will be able maintains usual
craniotomy defects, absorbing and to: level of
bilateral parietal coolant properties a) Display growing 4. Checked Hemoglobin levels  Low levels reduce the consciousness
bones with overlying of the water in tolerance to uptake of oxygen at the  If the patient still
soft tissue swelling. blood plasma and its activity alveolar-capillary has events of
variable rate of flow confusion a few
--Atherosclerotic through the skin, b) Verbalize or
intracranial arteries. where excess heat
can be lost from the
blood to the
environment. Blood
can clot, which
protects against its
excessive loss from
the cardiovascular
system after an
injury. In addition, its
white blood cells
protect against
disease by carrying
on phagocytosis.
Several types of
blood proteins
including antibodies,
interferons, and
complement, help
protect against
disease in a variety
of ways. However,
conditions such as
conditions such as
amputation,
cerebrovascular
accident, stroke,
crainiocerebral
trauma, disk
surgery, myocardial
infarction, sepsis,
thrombophebitis,
deep vein
membrane and oxygen hours after
demonstrate delivery to the tissues. reorientation to
normal time, place, and
sensations and person.
movement as 5. Assessed for presence of  Nonexistence of  If the patient
appropriate. pallor, cyanosis, mottling, peripheral pulses must maintains a warm
cool or clammy skin. Assess be reported or and dry skin, but
quality of every pulse. managed immediately. have episodes of
Systemic cold extremities.
vasoconstriction  If the patient still
resulting from reduced needs full
cardiac output may be assistance to
manifested by some activities,
diminished skin but can move on
perfusion and loss of his own when
pulses. Therefore, turning or
assessment is required repositioning on
for constant bed.
comparisons.  If the patient
shows slight
6. Maintained optimal cardiac  This ensures adequate improvement on
output. perfusion of vital sensations and
organs. motor activity.
7. Controled environmental  Fever may be a sign of
temperature as necessary. damage to UNMET
Perform tepid sponge bath hypothalamus. Fever  If the patient does
when fever occurs. and shivering can not show any
further increase ICP. improvement in
his level of
8. Reviewed laboratory result  To know the type of consciousness
interventions given to  If the patient is
patient. confused during
the whole shift,
thrombosis, upper even after
gastrointestinal THERAPEUTICS: reorientation to
bleeding and time, place, and
atherosclerosis 1. Promoted passive ROM  Exercise prevents person.
causes reduction in exercises. venous stasis and  If the patient has
arterial blood flow further circulatory cold, clammy
that leads to compromise. extremities.
deprived nutrition  If the patient still
and oxygenation at 2. Administered medications  These medications needs full
the cellular level. as prescribed to treat facilitate perfusion for assistance in all
Decreased tissue underlying problem. Note most causes of activities and is
perfusion can be the response. impairment. dependent to
transient with few another person.
or minimal  Antiplatelets/anticoagulants  If the patient
consequences to the --These reduce blood viscosity shows no
health of the and coagulation. improvement in
patient. If the  Peripheral vasodilators sensations and
decreased perfusion --These enhance arterial dilation movement.
is acute and and improve peripheral blood
protracted, it can flow.
have devastating  Antihypertensives
effects on the --These reduce systemic vascular
patient. Diminished resistance and optimize cardiac
tissue perfusion, output and perfusion.
which is chronic in  Inotropes
nature, invariably --These improve cardiac output.
results in tissue or
organ damage or 3. Provided oxygen therapy as  This saturates
death. necessary. circulating hemoglobin
and augments the
efficiency of blood that
is reaching the ischemic
tissues.
4. Positioned patient properly
in a semi-Fowler’s to high-
Fowler’s as tolerated.
5. Elevated edematous legs as
ordered and ensure that
there is no pressure under
the knee.
6. Applied support hose as
ordered.
EDUCATIVE:
1. Encouraged the family
members to do passive
flexion exercises in bed.
 Upright positioning
promotes improved
alveolar gas exchange.
 Elevation improves
venous return and helps
minimize edema.
Pressure under the knee
limits venous
circulation.
 Wearing support hose
helps decrease edema.
 Flexion exercises helps
to enhance circulation.