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SCIENTIFIC EXPECTED

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE


EXPLANATION OUTCOME
S>Ø Ineffective Cerebral Perfusion is the process Short term: >Establish rapport >To gain the client and The client and the
O> the pt. manifested Tissue Perfusion r/t of nutritive delivery of SO’s trust. SO shall have
the ff. Space Occupying arterial blood to a After 4-5° of NI, the >Monitor VS. >To obtain data for verbalized
Lesion (Neuroblastoma capillary bed in the client and the SO will >Reviewed laboratory comparison. understanding of
 Altered mental on Frontal Lobe) biological tissue. When a be able to verbalize results >To evaluate condition, therapy
status lump or a mass occluded understanding of >Determine factors r/t underlying causes. regimens, and when
 Speech blood vessels or condition, therapy individual situation >To assess contributing to contact
abnormalities capillaries, these will regimens, and when to >Assess mood changes, factor. healthcare provider.
 Restlessness result to ineffective contact healthcare memory and motor
 Changes in nutrition of the affected provider. changes >To note degree of The client shall have
pupillary part thus, may result to >Provide information impairment demonstrated
reaction AEB (-) loss of function of the Long term: regarding the client’s increased perfusion,
pupil reaction said part and later on condition. >To increase the SO’s as individually
to light. affect to body After 6-7 days of NI the knowledge about the appropriate AEB VS
systematically. client will be able to >Note Hx. of dse. condition. are on client’s
demonstrate increased brief/intermittent periods >To evaluate normal range, alert
The Frontal lobe of the perfusion as of confusion/blackout. occurrence of TIA and oriented.
brain is responsible for individually appropriate >Interview SO regarding
memory, AEB VS are on client’s their perception of >To assist SO in
emotion/behaviors, and normal range, alert and situation understanding the
motor function; damages oriented. >Review medication. client’s condition.
to this area may result to >To evaluate possible
behavioral changes, loss >Elevate HOB and adverse effect to the
of memory, and maintain head/neck in client’s condition.
paralysis. In the event, midline/neutral position >To promote
damages happen to the >Administer medications circulation/venous
frontal lobe, it will lead to as ordered drainage
restlessness, which may >Prepare pt. for surgery
contribute to as indicated (Space >To pharmacologically
susceptibility to injury, it Occupying Lesion) manage client’s
may also result paralysis. >Refer to ND Decreased condition.
Intracranial Adaptive >To maximize tissue
When ineffective Capacity perfusion.
perfusion to the frontal >Refer accordingly
lobe occurs, this will lead
to loss of function of the >To manage other
frontal lobe that will actual client’s problem
greatly affect the body, >To have a continuous
which may lead to client’s care
respiratory/cardiac arrest
since motor function
includes muscle
contraction.
SCIENTIFIC EXPECTED
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE
EXPLANATION OUTCOME
S>Ø Ineffective Cerebral Perfusion is the process Short term: >Establish rapport >To gain the client and The client and the
O> the pt. manifested Tissue Perfusion r/t of nutritive delivery of SO’s trust. SO shall have
the ff. Space Occupying arterial blood to a After 4-5° of NI, the >Monitor VS. >To obtain data for verbalized
Lesion (Neuroblastoma capillary bed in the client and the SO will >Reviewed laboratory comparison. understanding of
 Altered mental on Frontal Lobe) biological tissue. When a be able to verbalize results >To evaluate condition, therapy
status lump or a mass occluded understanding of >Determine factors r/t underlying causes. regimens, and when
 Speech blood vessels or condition, therapy individual situation >To assess contributing to contact
abnormalities capillaries, these will regimens, and when to >Assess mood changes, factor. healthcare provider.
 Restlessness result to ineffective contact healthcare memory and motor
 Changes in nutrition of the affected provider. changes >To note degree of The client shall have
pupillary part thus, may result to >Provide information impairment demonstrated
reaction AEB (-) loss of function of the Long term: regarding the client’s increased perfusion,
pupil reaction said part and later on condition. >To increase the SO’s as individually
to light. affect to body After 6-7 days of NI the knowledge about the appropriate AEB VS
systematically. client will be able to >Note Hx. of dse. condition. are on client’s
demonstrate increased brief/intermittent periods >To evaluate normal range, alert
The Frontal lobe of the perfusion as of confusion/blackout. occurrence of TIA and oriented.
brain is responsible for individually appropriate >Interview SO regarding
memory, AEB VS are on client’s their perception of >To assist SO in
emotion/behaviors, and normal range, alert and situation understanding the
motor function; damages oriented. >Review medication. client’s condition.
to this area may result to >To evaluate possible
behavioral changes, loss >Elevate HOB and adverse effect to the
of memory, and maintain head/neck in client’s condition.
paralysis. In the event, midline/neutral position >To promote
damages happen to the >Administer medications circulation/venous
frontal lobe, it will lead to as ordered drainage
restlessness, which may >Prepare pt. for surgery
contribute to as indicated (Space >To pharmacologically
susceptibility to injury, it Occupying Lesion) manage client’s
may also result paralysis. >Refer to ND Decreased condition.
Intracranial Adaptive >To maximize tissue
When ineffective Capacity perfusion.
perfusion to the frontal >Refer accordingly
lobe occurs, this will lead
to loss of function of the >To manage other
frontal lobe that will actual client’s problem
greatly affect the body, >To have a continuous
which may lead to client’s care
respiratory/cardiac arrest
since motor function
includes muscle
contraction.