1. Ineffective Cerebral Tissue Perfusion related to cessation of blood flow by SOL
evidenced by: changes in the level of consciousness, loss of memory, changes in response to motor / sensory, anxiety and changes in vital signs.
Outcomes: The patient will be maintained level of awareness, improved cognition, motor function / sensory, stable vital signs, no signs of increased ICP.
Intervention:
- Determine the cause of decreased tissue perfusion.
- Monitor neurologic status on a regular basis and compare with the standard value (GCS).
- Monitor vital signs.
- Assess changes in vision and state of the pupil.
- Assess the reflexes (swallowing, coughing, Babinski).
- Monitor fluid intake and output.
- Auscultation of breath sounds, note the presence of hypoventilation, and additional sound abnormal.
- Monitor blood gas analysis.
- Give the drug as indicated.
- Give oxygenation.
2. Risk for ineffective breathing pattern related to neurovascular damage, cognitive impairment.
Outcomes: The patient can be maintained effective breathing patterns, free cyanosis, the blood gas analysis within normal limits.
Intervention:
- Assess and record the change in frequency, rhythm, and depth of breathing.
- Raise the head of the bed by the rules / oblique position as indicated.
- Encourage deep breathing, if the patient is conscious.
- Do suction mucus with caution no more than 10-15 seconds, record the character color, viscosity and turbidity of secretions.
- Monitor pengguanaan depressant drugs.
Collaboration:
- Give oxygenation as indicated.
- Perform chest physiotherapy if indicated.
3. Pain (acute / chronic) related to
agent of physical injury, nerve compression by SOL, increased ICT
characterized by: pain states because of changes in position, pain, pale around the face, cautious behavior, anxiety inclined positions of pain, decreased activity tolerance, self-narrowing focus on themselves, faces seemed to withstand pain, change in sleeping patterns, withdrawal physical.
Outcomes: patients report reduced pain, showed behavior to reduce recurrence or pain.
Intervention:
- Assess complaints of pain.
- Observation of nonverbal pain states (eg; facial expressions, restlessness, crying, withdrawal, diaphoresis, changes in heart rate, respiration and blood pressure.
- Suggest to rest.
- Give moist heat compresses to the head, neck, arms as needed.
- Do the massage in the head / neck / arm if the patient can tolerate touch.
- Give analgesics as indicated.
- Give antiemetics as indicated.
1 Comment for "Space-occupying Lesions (SOL) - 3 Nursing Diagnosis and Interventions"
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