Nursing Diagnosis 1. :
Ineffective Cerebral Tissue Perfusion increased intracranial pressure.
1. Observe evidence of increased ICP (a change of consciousness, vomiting, headache, increased blood pressure, seizures, bradycardia, slow and irregular breathing), report immediately if any.
R /: It is very important in preventing dangerous or life-threatening complications.
2. Observation of vital signs (BP, pulse, respiration and temperature)
R /: Changes in the client’s vital signs can provide an overview of post surgical complications, poor prognosis disease.
3. Monitor post-surgical drainage of cerebrospinal fluid by a bulge the size monitors crown, measure the circumference of the head per day
R /: Drainage of cerebrospinal fluid overload can be suspected occurrence of a progressive brain damage and assist in taking further action.
4. Place the head in an elevated position of 15-30 degrees
R /: Lowering the arterial pressure and improve drainage and circulation / cerebral perfusion.
5. Help prevent straining during defecation and respiratory pressure (persistent cough)
R /: Valsalva maneuver may increase the ICT and increase the risk of hemorrhage.
6. Create a calm environment. Provide periodic breaks between maintenance activities, and limit the duration of each procedure.
R /: Activities / continuous stimulation may Increasing ICT.
7. Management of luminal appropriate therapy medical program.
R /: Therapy luminal sedatives contain substances that can help reduce seizure activity.
Nursing Diagnosis 2:
Imbalanced Nutrition Less Than Body Requirements related to inadequate food intake
1. Assess the child’s preferred foods and foods that do not induce vomiting
R /: so easy choosing and serving food
2. Give the food a little but often
R / to maintain a stable weight in order not to fall dramatically and also no nausea
3. Serving food while warm
R / with serving food while warm add the patient’s appetite
4. Assist and accompany clients during meal
R /: to give support and encouragement to the client.
5. Collaboration to provide IV fluid line
R / infusion of fluids through an IV to add nutrients and fluids for patients with nausea and vomiting
Nursing Diagnosis 3 :
Risk for injury related to increased intracranial pressure.
1. With careful observation for signs of increased ICP (a change of consciousness, vomiting, headache, increased blood pressure, seizures, bradycardia, breathing slow and irregular)
R /: action to prevent delays.
2. Perform assessment on preoperative neurological basis.
R /: as a guideline for postoperative assessment and evaluation of shunt function.
3. Avoid intravenous infusion in the vein of the scalp when the surgery will be performed.
R /: because the procedure will affect the IV.
4. Position the child in accordance with (placed on the side that is not in operation).
R /: to prevent pressure on the shunt valve.
5. Elevate head of bed if instructed.
R /: to increase the gravity flow through the shunt.
6. Avoid sedation
R /: because the level of awareness is an important indicator of increased intracranial pressure.
7. Teach the patient’s family about the signs of increased ICP and when to inform practitioners of nursing.
R /: action to prevent delays.
Nursing Diagnosis and Nursing Interventions for Hydrocephalus