Intraventricular Hemorrhage Nursing Diagnosis

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hello all, i am new to the forum and i would appreciate some assistance formulating an appropriate nursing diagnosis for an intraventricular hemorrhage medical diagnosis. my patient is an extremely premature, elbw, neonate in the nicu. i am leaning toward ineffective tissue perfusion: cerebral r/t hypervolemia of cerebral ventricles; however, i have been working on this care plan for so many hours that i am just not sure if i am loving this diagnosis. thanks for any imput that can be provided.

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what i really need is help with the aeb in this diagnosis....

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i know that is hard to keep medical diagnoses and nursing diagnoses separate, but they are two different animals--as different as apples and oranges. but they are both arrived at through a similar thinking process: doctors use the medical decision making process and we nurses use the nursing process. what you have for a nursing diagnostic statement has a problem and etiology. it sounds correct although no other information about the patient is known except for the hemorrhage. checking the nanda taxonomy tells me that "hypervolemia of cerebral ventricles" is a proper etiology for this diagnosis although it could be shortened to just "hypervolemia" if you like. normally, students are also expected to provide evidence (symptoms) to support using a diagnosis as well. those symptoms would be some of the cerebral defining characteristics listed on these nursing diagnosis pages: [color=#3366ff]ineffective tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55

perhaps the reason you are not loving this diagnosis is because you need more information about the medical condition elbw. intraventricular hemorrhage is seen in extremely low birth weight babies.

when care planning, follow the steps of the nursing process:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

  • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
  • your instructors might have given it to you.
  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    • care/perform/provide/assist (performing actual patient care)
    • teach/educate/instruct/supervise (educating patient or caregiver)
    • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

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Specializes in med/surg, telemetry, IV therapy, mgmt.
what i really need is help with the aeb in this diagnosis....

you are backing into the diagnosing of the problem. you are saying, in effect, that you have a problem and are looking for symptoms to prove the problem exists. that is not the proper way to diagnose. see what i just posted above. you need to have done a thorough assessment of this patient to find the symptoms of the cerebral hypoxia first. look for altered loc and motor responses, weakness and paralysis in this baby.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

did some searching and found a few links that have very good information with the symptoms, diagnosis and treatment of ivh (intraventriculqar hemorrhage). these kids sometimes go on to have cerebral palsy and developmental delays.

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Specializes in NICU, Infection Control.

I don't think you see those signs--what I've seen when a baby has had an acute IVH is decrease in BP, increase in head circumference, widening of the sutures, change in color (from pink to gray and mottled); might also see alteration in thermoregulation, needing more heat from the bed. A decrease in urine coincides w/a decrease in BP.

If the IVH is not resolving, you start to see signs of hydrocephalus--sunset eyes, tremors, increased DTRs. Later, there could be signs of Developmental Delay. including feeding issues.

An acute bleed is a medical emergency.

I don't know how to fit this stuff into the framework, unfortunately.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

The OP needs one or more symptoms to go along with the diagnostic statement

Ineffective Tissue Perfusion: cerebral R/T hypervolemia of cerebral ventricles AEB . . .

What I don't know is if this was a real patient or if this is a simulation.

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