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This Concept Map has information related to: clinical sept 26 2007graded 10 points, tylenol tab 650mg PO nonnarcotic analgesic Good, Test & Diagnostics CBC: WBC: 17.7 Hct: 26.2 Hgb: 7.9 RBC: 4.9 increase WBC indication of sepsis (nursing dx: risk for infection) low hct/hgb may be due to surgery blood loss, Procedures ventricolostomy, ineffective tissue perfusion related to s/p surgery wound, risk for DVT due to immobility, Test & Diagnostics blood/CSF culture suspecting sepsis but results not in yet, Test & Diagnostics CMP: Na: 137 K: 3.9 BUN: 9 Cr: 0.82 mg:1.7 -high Na and K may be due to overload of maintainence fluid, Admission Dx nursing dx: hyperthermia risk for infection, Admission Dx nursing dx: hyperthermia related to subarchnoid bleeding, interventions: -pt demonstrate stable ICP -maintain head/neck in neutral position due to right side neglect -provide rest period between care -increase blood pressure to the brain ???? pt will: -demonstrate stable ICP -display improve or WNL of neuro -display ICP drainage -B/P will increase, norenephrine 8mg, IV drip D5W 250ml titrate to maintain BP parameters nursing Dx decreased cardiac output: reason for the drug is to increase B/P to greater than 168 for this neuro patient interventions: -determine baseline VS and hemodynamic parameters -assess ECG, CVP, arterial B/P, ICP hourly