Nursing Care Plan

NURSING CARE PLAN
In Partial Fulfillment of the
Requirements in NCM 216-RLE
PC/OR NURSING ROTATION
Submitted to:
Mrs. Erein Therese Acero, RN, MN
Clinical Instructor
Submitted by:
Sherie Mae D. Andaya, St.N
BSN 3E-Group 1
February 03, 2021

NURSING CARE PLAN
Name of Patient: __________________________________________ Age/Gender: ______________ Ward: __________ Room no.___________

Chief Complaint: _________________________________________________________________ Physician: ____________________________
Diagnosis: ___________________________________________________________________________________________________________
Date/ Cues Need Nursing Diagnosis Objectives of Care / Patient Nursing Interventions Implementation Evaluation
Time Outcome
Subjective: A Ineffective cerebral After 1 week of rendering • Closely monitor 1
C tissue perfusion related appropriate nursing patient for neurologic
“Matagal ng T to interruption of blood intervention, the patient will deterioration
highblood ang I flow secondary to be able to:
resulting from
mister ko” V hemorrhage
I a. Maintain recurrent bleeding,
“Nahihilo at T Rationale: usual/improved level increasing ICP, or
sumasakit daw Y of consciousness, vasospasm.
ang ulo niya Too much pressure in
cognition, and
kaya dinala A the vessels can cause it R: Assesses trends in level
namin dito” N to rupture and thus motor/sensory
of consciousness (LOC)
D leads to hemorrhage. If function and potential for increased
hemorrhage occurs in b. Maintain normal ICP and is useful in
Objective: E the brain, there would blood pressure and determining location, extent,
X be increased absence of signs of and progression/resolution
Altered LOC E intracranial pressure increased ICP of CNS damage.
R and the brain will start
c. Improve tissue
Slurred C to swell. Therefore, • Monitor vital signs 3
speech I there would be not perfusion
S enough blood flow and R: Fluctuations in pressure
E may occur because of
Changes in oxygenation in the cerebral pressure/injury in
pupillary P brain. vasomotor area of the brain.
reactions A
T Reference: • Monitor respiratory 4
Changes in T status
motor E Textbook of Medical
response; R Surgical 12th edition by R: A reduction in oxygen in
Weakness N Brunner and areas of the brain with
Suddharths pg. 563 impaired autoregulation
BP: 190/110 increases the chances of
mmHg cerebral infarction.
GCS of 11 5
• Position the head of
bed elevated 30
degree
R: To promote venous
drainage and decrease ICP.
• Maintain bedrest, 7
provide quiet and
relaxing environment,
restrict visitors and
activities. Cluster
nursing interventions
and provide rest
periods between care
activities. Limit
duration of
procedures.
R: Continuous stimulation or
activity can increase ICP.
Absolute rest and quiet may
be needed to prevent re-
bleeding in the case of
hemorrhage.
• Evaluate eye
opening 2
R: Establishes arousal
ability or level of
consciousness.
• Administer
5
supplemental oxygen
as indicated.
R: Reduces hypoxemia.
Hypoxemia can cause
cerebral vasodilation and
increase pressure or edema
formation.
• Administer 6
medications
prescribed by the
doctor
R: To promote
pharmacological treatment
regimen
• Assess for signs of 9

possible vasospasm:
intensified
headaches, decrease
level of
responsiveness
(confusion,
disorientation,
lethargy), or
evidence of aphasia
or partial paralysis.
R: These signs may

develop several days after
surgery or on the initiation
of treatment and must be
reported immediately.
• Avoid measures that 8

may trigger
increased ICP such
as coughing,
vomiting, straining at
stool, neck in flexion,
head flat, or bearing
down.
R: These will further reduce

cerebral blood flow.
• Reorient to
10
environment as
needed.
R: Decreased cerebral
blood flow or cerebral
edema may result in
changes in LOC. Sherie Mae
D. Andaya,
Textbook of Medical St.N
Surgical 14th edition by BSN 3E-
Brunner and Suddharths Group 1
Vol 1&2
INDIVIDUAL CLUSTERING
Health Nutritional Elimination Activity Exercise Sleep Cognitive- Self- Role- Sexuality- Coping- Value-
Management/ Metabolic Pattern Pattern Rest Perceptual Perceptio Relationship Reproduc Stress Belief
Health Pattern Pattern Pattern n-Self- Pattern tive Tolerance Pattern
Perception Concept Pattern
Pattern
Headache High blood Altered Slurred

LOC speech
BP: 190/110 mmHg
Changes in
Changes in motor pupillary
response; reactions
Weakness
GCS of 11
Dizziness/Nauseous
Gordon’s Functional Health Pattern

Group Clustering
Health Perception/Health Nutritional Metabolic Elimination Activity Exercise
Management Pattern
● Severe Headache ● Pale Lips ● Experiencing urinary ● Passive range of motion
● Drinks alcohol 1 liter per ● Skin slowly moves back to incontinence exercise
day its previous state when ● Functional Level Codes:
pinched. -Level III: requires
● Difficulty of swallowing assistance or supervision
from another person and
equipment or device
● Kyphotic posture
● High blood
● BP: 190/110 mmHg
● Changes in motor
response; Weakness
● Right-sided weakness
● Poor hand gripping
● Movement-induced tremor
● Slowed movement
● Restlessness
● Activity intolerance or
fatigue
Cognitive Perceptual Sleep Rest Self-Perception/ Self Concept Role Relationship
● Altered LOC ● Performing self-care ● Decreased use of social
● changes in pupillary activities within the level of support
reactions his own ability
● GCS: 11
● RLS: 2
● Slurred speech
● Poor concentration
● Difficulty in constructing
statements or phrases
● Difficulty in identifying
objects.
Sexuality-Reproductive Coping Stress Mechanism Value Belief Nursing Priorities

Nursing Care Plan

Uploaded by

Copyright:

Available Formats

Nursing Care Plan

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nursing Care Plan

Uploaded by

Copyright:

Available Formats

NURSING CARE PLAN

In Partial Fulfillment of the

Requirements in NCM 216-RLE

PC/OR NURSING ROTATION

Mrs. Erein Therese Acero, RN, MN

Sherie Mae D. Andaya, St.N

February 03, 2021

Name of Patient: ____________________________ Age/Gender: Ward: Room no._

• Assess for signs of 9

R: These signs may

• Avoid measures that 8

R: These will further reduce

Headache High blood Altered Slurred

Gordon’s Functional Health Pattern

You might also like