Goals:
- Patient's neurological status returned to the state before the illness.
- Increased patient awareness and sensory function.
Outcomes:
- Vital signs within normal limits.
- Reduced headache pain.
- Increased awareness.
- No signs or loss of increased intracranial pressure.
Intervention:
1. Total bedrest patients, with supine sleeping position without a pillow.
Rationale: Changes in inta-cranial pressure will be able to mislead the risk for brain herniation.
2. Monitor signs of neurological status with GCS.
Rational: It can reduce further brain damage.
3. Monitor vital signs such as blood pressure, pulse, temperature, respiration and caution in systolic hypertension.
Rational: In normal circumstances autoregulation maintains a state of altered systemic blood pressure fluctuation. Autoregulation failure will cause a cerebral vascular damage can be manifested by an increase followed by a decrease in systolic and diastolic pressure. While the increase in temperature can describe the course of infection.
4. Monitor intake and output
Rational: Hyperthermia can lead to increased IWL and increase the risk of dehydration, especially in patients who are not aware, and nausea were lower intake by mouth
5. Help the patient to limit vomiting, coughing. Instruct the patient to exhale when moving or turning in bed.
Rationale: Activity vomiting or coughing can increase intracranial and intra-abdominal pressure. Exhale when moving or changing position can protect themselves from the effects of Valsalva.
6. Give fluids per infusion with strict attention.
Rationale: Minimize the burden of vascular and fluctuations in intracranial pressure, fluid and fluid vetriksi can reduce cerebral edema.
7. Monitor blood gas analysis of oxygen delivery when needed.
Rational: The possibility of acidosis is accompanied by the release of oxygen at the cellular level may lead to the occurrence of cerebral ischemic.
8. Provide appropriate therapy such as physician advice: Steroids, Aminofel, Antibiotics
Rational Therapy given to decrease capillary permeability.
Lowering of cerebral edema
Lowered metabolic cells / consumption and seizures.
Source : http://nurseskomar.blogspot.com/2013/07/ineffective-tissue-perfusion-related-to.html