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Mindanao Sanitarium and Hospital College

Department of Nursing


Name: Baby Hydro Age: 39 days old Gender: Male
Chief Complaints: Room No:
Problem Identified: Hydrocephalus
Nursing Diagnosis: Decreased Intracranial Adaptive Capacity r/t Space- Occupying Lesion.
Cause Analysis: ( With Ref.) Intracranial pressure, (ICP), is the pressure exerted by the cranium on the brain tissue, cerebrospinal fluid (CSF), and the brain's circulating blood volume. ICP is a dynamic phenomenon
constantly fluctuating in response to activities such as exercise, coughing, straining, arterial pulsation, and respiratory cycle. An increase in pressure, most commonly due to head injury leading to intracranial
hematoma or cerebral edema can crush brain tissue, shift brain structures, contribute to hydrocephalus, cause the brain to herniate, and restrict blood supply to the brain, leading to an ischemic cascade. If left
untreated the patient may result to coma or worst death. (Medical Surgical Nursing by Ignatavicius)

Cues Objectives Nursing Intervention Rationale Evaluation

SUJECTIVE: SHORT TERM: INDEPENDENT: The SO shall have understand the

- inceased head circumference To gain the client and SO’s trust. client’s condition and be able perform
>Establish rapport
(37cm) After 1-2° of NI the SO will be able to actively in promoting the clients condition
- abnormal reflexes (no rooting, understand the client’s condition and be >To obtain data for comparison. having now a higher level of
>Monitor VS.
and moro reflexes) able perform actively in promoting the understanding of the client’s condition
clients condition having now a higher >To alter care appropriately. and the complications that may occur.
>Monitor/document changes in ICP
- a bulging forehead with level of understanding of the client’s waveform and responses to stimuli.
prominent fontanel, a slowed condition and complications that may
heartbeat occur. >Assess eye opening and The client shall have demonstrated
> To note degree of impairment
position/movement, Pupils (size, stable ICP and normalization of pressure
- respiratory rate equality, light reactivity), purposeful and
LONG TERM; non-purposeful motor response waveforms/response to stimuli.
- a thin transparent scalp. comparing left and right sides, presence
After 6-7 days of NI the client will be able of reflexes, nuchal rigidity,
to demonstrate stable ICP, normalization consciousness and mental state. >To increase SO’s understanding of the
of pressure waveforms/response to client’s condition and will be able to
>Provide information about the client’s decide properly for the client’s care.
condition including the complications
which may arise once untreated

>Elevate HOB and maintain head/neck >To promote circulation/venous drainage

in midline/neutral position
>To reduce CNS stimulation and
>Decrease extraneous stimuli/provide promote relaxation.
comfort measures
>To decrease factors which may
>Limit activities that increases contribute in further increasing ICP.
intrathoracic/abdominal pressure
>Administer medications as
ordered (e.g. antihypertensives, >To pharmacologically manage
diuretics, analgesics, antipyretics, client’s condition and maintain
vasopressors, antiseizure, homeostasis
neuromuscular blocking agents,
and corticostreiods)

>Prepare pt. for surgery as

indicated (Space Occupying
>To reduce ICP and enhance
>Refer accordingly
>To have a continuous client’s

References: Nursngg Care Plan by Marilyn Doenge