Primary Nursing Diagnosis

Altered thought process related to cerebral tissue injury and swelling

OUTCOMES. Cognitive ability; cognitive orientation; Concentration; decision making; Identity; Information processing; Memory; Neurological status: Consciousness

INTERVENTIONS. Cerebral perfusion promotion; Environmental management; Surveillance; Cerebral edema management; Family support; Medication management

U PLANNING AND IMPLEMENTATION Collaborative

If a lesion identified by computed tomography (CT) scan is causing a shift of intracranial contents or increased ICP, immediate surgical intervention is necessary. A craniotomy is performed to evacuate the ICH and ischemic tissue if the site is operable or to release ICP if viable tissue will be preserved.

Ongoing monitoring and serial assessments are essential. ICP monitoring and sequential CT scanning may be needed in critically ill patients, and serial neurological assessments are needed

530 Intracerebral Hematoma on all patients to determine if ICP is increasing. Because bleeding and swelling can progress over several days after injury, the patient is monitored for deterioration even up to 10 days after injury. During periods of frequent assessment, the patient should not be sedated for longer than 30 minutes at a time; longer-acting sedation may mask neurological changes and place the patient at risk for lack of detection.

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