- Ineffective Cerebral tissue Perfusion related to decrease cerebral blood flow and primary intracranial disease as evidenced by decreased level of consciousness and behavioral changes
- Acute Confusion related to alteration in brain function and delirium as evidenced by hallucinations and impaired cognition
- Risk for Injury related to alteration in brain function, Hypoxia and Intoxication evidenced by seizure activity
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Chest Pain Dyspnea Sense of impending doom Objective Data: -Arrhythmias -Capillary refill >3 seconds -Altered respiratory rate -Use of accessory muscles to breathe -Abnormal arterial blood gases -Unstable blood pressure -Tachycardia or bradycardia -Cyanosis | Ineffective Cerebral tissue Perfusion related to decrease cerebral blood flow and primary intracranial disease as evidenced by decreased level of consciousness and behavioral changes | To maintain adequate peripheral perfusion To maintain normal Cardiopulmonary perfusion | 1. Determine the appropriate level of care. Collaborate with the interdisciplinary team to determine the appropriate level of care. Patients with AMS related to cerebral perfusion likely require monitoring in the neuro-ICU by specially trained nurses. 2. Administer fluids and electrolytes as prescribed. Fluid resuscitation aims to improve cerebral tissue perfusion and hemodynamics. To compensate for losses and keep circulation and cellular function intact, provide fluids and electrolytes as needed. 3. Prepare the client for surgical procedure as indicated. The client may be a candidate for a surgical procedure such as carotid endarterectomy or evacuation of cerebral hematoma or lesion. The nurse must prepare for a possible surgical procedure to improve tissue perfusion in the brain. | Patient maintained adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient maintained cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient demonstrated appropriate lifestyle modifications to support adequate tissue perfusion. |
Subjective Data: Hallucinations Paranoia Objective Data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to alteration in brain function and delirium as evidenced by hallucinations and impaired cognition | Patient will be able to regain orientation to person, place, and time Patient will identify lifestyle changes to prevent acute confusion reoccurrence | 1. Provide constant orientation to person, place, and time as needed. Reorient as needed to person, place, time, and situation. Challenging illogical thinking may cause defensive reactions. Hence, presenting reality will help the client by eliminating confusion. 2. Prevent sundowning. The nurse can encourage the client to get plenty of exposure to light, maintain a routine of activities, limit napping during the daytime, and provide familiar objects. 3. Educate caregivers to monitor the client at home. Caregivers must know when to contact the healthcare provider for a sudden change or worsening in cognition and behavior. 4. Provide a stable and calm environment. Prevent worsening confusion and potential agitation by providing an environment that is quiet without overstimulation that allows for rest. | Patient regained orientation to person, place, and time Patient identified lifestyle changes to prevent acute confusion reoccurrence |
| Subjective Data: Report of seizure. Objective Data: -Altered level of consciousness (+) Seizure activity (+) Right sided weakness GCS 11 | Risk for Injury related to alteration in brain function, Hypoxia and Intoxication evidenced by seizure activity | Patient will be able to verbalize an understanding of risk factors that may cause injury Patient will identify behaviors and measures to reduce risk factors and protect themselves from injury Patient will remain free from injury | 1. Provide safe nursing care. The nurse must consider a culture of safety when implementing nursing care to promote client safety and serve as an example of safe conduct. 2. Inform the client about all treatments and medications. Communication with the client is essential because it builds and preserves trust. Clear communication can help the client feel less angry, worried, and depressed as well as increase cooperation with the implementation of care and improve the safety of the client. 3. Reduce the risk of injury. The nurse can identify safety measures and interventions that promote both individual and environmental safety. Examples include keeping the bed alarm on, keeping the call bell within reach, using assistive devices, and more. 4. Prepare the client for a safe home environment. Discuss safety measures to improve the home environment such as equipment needs, fall prevention, how to call for help, medication safety, and more. | Patients remained free from falls. Patients engaged in safe behavior and take action to reduce the chance of injury. Patients remained free from any form of self-harm. Patient remained free from any skin breakdown or impairment in skin integrity. |