Nursing diagnosis – DECREASED INTRACRANIAL ADAPTIVE CAPACITY

ADAPTIVE  CAPACITY

DEFINITION

Intracranial fluid dynamic mechanisms that normally compensate for

increases in intracranial volumes are compromised, resulting in

repeated disproportionate increases in intracranial pressure (ICP) in

response to a variety of noxious and nonnoxious stimuli

DEFINING CHARACTERISTICS

• Baseline ICP    10 mm Hg

• Disproportionate increase in ICP following single nursing

maneuver

• Elevated P2 ICP wave form

• Repeated increase of   10 mm Hg for more than 5 min following

external stimuli

• Volume pressure response test variation (volume–pressure ratio

greater than 2, pressure–volume index   10)

• Wide amplitude ICP waveform

RELATED FACTORS

• Brain injuries

• Sustained hypotension with

• Decreased cerebral perfusion

intracranial hypertension

• Sustained increased ICP

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac functioning

• Neurocognition

• Comfort

• Pharmacologic function

• Elimination

• Respiratory functioning

• Fluid and electrolytes

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Maintain effective breathing pattern and normal ABG levels.

• Show no evidence of fever.

• Modify environment to eliminate noxious stimuli.

• Maintain regular bowel function.

• Maintain skin integrity.

• Remain free of signs and symptoms of infection.

• Not show evidence of neurological compromise.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Neurological Status:

Consciousness; Wound Healing: Primary Intention

INTERVENTIONS AND RATIONALES

Determine: Assess vital signs, temperature, pulses, heart sounds,

jugular vein distension; electrocardiogram, history of hypertension;

mental status, reflexes, response to pain, papillary size and response

to light; respiratory rate, depth, and pattern of respiration, ABG,

pulse oximetry; monitor ICP wave forms for trends over time. Mon-

itor for damped waves. Assess cerebral perfusion pressure.

211

Assessment information will assist in identifying appropriate

interventions.

Perform: Maintain ICP monitoring systems if used. Careful attention

must be paid to ensure that the system is functioning to provide

accurate information. Use sterile technique for dressing changes to

prevent contamination of equipment and infection.

Maintain a patent airway and suction only if needed. Suctioning

stimulates coughing and Valsalva maneuver; Valsalva increases

intrathoracic pressure, decreases cerebral venous drainage, and

increases cerebral blood volume, resulting in increased ICP. Elevate

head of the bed 15 –30   or as ordered, and use sandbags, rolled

towels, or small pillows to keep head in a neutral position. Reposi-

tion patient by using a draw sheet to prevent atrophy. Use minimal

amount of stimuli when caring for the patient. Turn and reposition

patient every 2 hr to prevent atelectasis.

Perform ROM exercises to maintain muscle tone.

Inform: Teach patient and family those aspects of care in which they

can participate without feeling anxious. Instruct family members in

gentle stroking of patient’s face, arms, or hand. Touch by family

members may lower the ICP in some cases.

Attend: Provide nursing care in a calm, reassuring manner. Avoid

discussion of upsetting topics near the bedside. This helps prevent

emotional upset that can increase ICP. Encourage patient and family

to express feelings associated with diagnosis, treatment, and recov-

ery. Expression of feelings helps patient and family cope with treat-

ment.

Manage: Arrange for frequent multidisciplinary/family care

conference in order to keep care goal-oriented. Refer patient and

family to support group to help deal with the injury, diagnosis, or

recovery. Refer to social worker/case manager for follow-up care,

home assessment, home visits, and referral to community agencies.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Bedside Laboratory Testing; Cerebral

Edema Management; Fluid–Electrolyte Management; ICP Monitoring

Reference

Littlejohns, L., & Bader, M. K. (2005, October–December). Prevention of sec-

ondary brain injury: Targeting technology. AACN Clinical Issues, 16(4),
501–514.

Nursing diagnosis – decreased cardiac output

Decreased Cardiac Output

DEFINITION

Inadequate blood pumped by the heart to meet metabolic demands of the body

DEFINING CHARACTERISTICS

• Altered heart rate and rhythm

• Abnormal heart rate response to activity

• Arrhythmias, palpitations, electrocardiographic changes

• Abnormal chest x-rays and cardiac enzymes

• Electrocardiographic changes reflecting ischemia

• Exertional discomfort

• Exertional dyspnea

• Verbal report of fatigue

• Verbal report of weakness

• Crackles

• Cough

• Anxiety/restlessness

RELATED FACTORS

• Altered afterload

• Altered heart rhythm

• Altered contractility

• Altered preload

• Altered heart rate

• Altered stroke volume

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Activity/exercise

• Respiratory function

• Fluid and electrolytes

EXPECTED OUTCOMES

The patient will

• Maintain pulse within predetermined limits.

• Maintain blood pressure within predetermined limits.

• Exhibit no arrhythmias.

• Maintain warm and dry skin.

• Exhibit no pedal edema.

• Maintain acceptable cardiac output.

• Verbalize understanding of reportable signs and symptoms.

• Understand diet, medication regimen, and prescribed activity level.

SUGGESTED NOC OUTCOMES

Cardiac Pump Effectiveness; Circulation Status; Tissue Perfusion:

Peripheral; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor patient at least every 4 hr for irregularities in

heart rate, rhythm, dyspnea, fatigue, crackles in lungs, jugular venous

distension, or chest pain. Any or all of these may indicate impending

cardiac failure or other complications. Report changes immediately.

Perform: Administer oxygen as ordered to increase supply to

myocardium.

Turn and reposition patient at least every 2 hr. Establish a turning

schedule for the dependent patient. Post schedule at bedside and

monitor frequency. Turning and repositioning prevent skin

breakdown and improve lung expansion and prevent atelectasis.

Administer antiarrhythmic drugs, as ordered, to reduce or elimi-

nate rhythm disturbances. Monitor for adverse effects.

Administer stool softeners, as prescribed, to reduce straining dur-

ing bowel movements.

Measure and record intake and output. Decreased urinary output

without decreased fluid intake may indicate decreased renal

perfusion resulting from decreased cardiac output.

Weigh patient daily before breakfast to detect fluid retention.
Perform active or passive ROM exercises to all extremities every

2–4 hr. ROM exercises foster muscle strength and tone, maintain

joint mobility, and prevent contractures.

Inspect legs and feet for pedal edema.
Maintain dietary restrictions, as ordered, to prevent fluid

retention, dehydration, weight gain or loss.

Gradually increase levels of activity within prescribed limits of

cardiac rate to allow heart to adjust to increased cardiac demands.

Inform: Educate patient and his or her family about chest pain and

other reportable symptoms, prescribed diet, medications (name,

dosage, frequency, and therapeutic and adverse effects), prescribed

activity level, simple methods of lifting and bending, and stress-

reduction techniques. Education promotes remembering of and com-

pliance with techniques to reduce energy consumption.

Attend: Provide emotional support and encouragement to help

improve patient’s self-concept.

Involve patient in planning and decision making. Having the ability to

participate will encourage greater compliance with the plan of treatment.

Have patient perform self-care activities. Begin slowly and increase

daily, as tolerated. Performing self-care activities will assist   patient

to regain independence and enhance self-esteem.

Manage: Refer to case manager/social worker to ensure that a home

assessment has been done and that whatever modifications are

needed to accommodate the patient’s ongoing care have been made.

Refer to cardiac program for exercise when the time is appropriate.

SUGGESTED NIC INTERVENTIONS

Cardiac Precautions; Circulatory Precautions; Fluid Management;

Homodynamic Regulation; Vital Signs Monitoring

Reference

Kodiath, K., et al. (2005). Improving quality of life in patients with heart failure:

An innovative behavioral intervention. Journal of Cardiovascular Nursing,
20(1), 43–48.