NOVILYN C.

PATARAY
BSN - II
ASSESSMENT DIAGNOSI PATHOPHYSIOLOG PLANNING INTEREVENTION RATIONALE EVALUATION
S Y
Subjective: Ineffective Hydrocephalus is After 8 hours of  Monitor  Fever may After 8 hours of
“napansin ko nga cerebral characterized by an nursing temperature. reflect damage nursing
haan nga normal ti tissue abnormal increase in interventions, the Administer to interventions, the
pinagdakkel toy ulo perfusion cerebrospinal fluid patient will tepid sponge hypothalamus. patient was able to
ti anak ko.” As related to volume within the demonstrate bath in Increased demonstrate
verbalized by the decreased intracranial cavity and improved vital presence of metabolic needs improved vital
patient’s mother. arterial or by enlargement of the signs and fever and oxygen signs and absence
venous head in infancy. absence of signs  Monitor intake consumption of signs of
Objective: blood flow. of increased ICP. and output. occur. increased ICP.
 Restlessnes Weigh as  Useful indicators
s indicated. of body water,
 Irritability Note skin which is an
 Changes in turgor, status integral part of
vital signs and mucous tissue perfusion
 V/S taken as membrane  Turning bed to
follows:  Maintain head one side
T- 37.5 or neck in compresses the
PR-90 midline or in jugular veins
RR-22 neutral and inhibits
BP-120/90 position, cerebral venous
support with drainage.
small towel
rolls and
pillows.