Henriette Jane De Leon BN3A January 21, 2021

Nursing Care Plan

Patient’s Name: AB Age: 65 y/o Sex: Male Diagnosis: CVD Bleed Right Thalamus and Internal Capsule

Assessmen Pathophysiologic/ Nursing

Nursing Diagnosis Desired Outcome Rationale Evaluation
t Cues Schematic Diagram Intervention

Subjective After 8 hours of Independent Independent After 8 hours of

Cues: Nursing Interventions: Interventions: Nursing
Imbalanced Predisposing Factors:
Intervention, the Intervention, the
Significant Nutrition; less than patient and 1. Assess the 1. Assessing the patient and
 Age
other body requirements r/t significant other patient and patient with significant other
 Sex
complaine vomiting aeb will be able to: the the causes of was able to:
d of patient presence of 125 ml Nasogastri vomiting will
vomiting gastric content output c Tube to guide the
Precipitating Factors:
during Short term goals: determine choice of Short term goals:
feeding;  Lifestyle the cause interventions
SO  Occupation of to be used.
 Smoking 1. Demonstrate 1. Demonstrate
verbalized vomiting. Treatment may
Definition: maintenance maintenance
“Nurse!  Hypertension not be needed
Vomiting is the of nutritional of nutritional
Nag suka if the stimulus
strong evacuation of intake intake on the
siya, is eliminated.
according to next feeding
patawag one's stomach  Intracerebral
his current time.
ko please contents through the hemorrhage caused
specified Medication
doctor kay mouth and at times by hypertension or 2. Check the 2. To check the
diet. was given
basi kung the nose, medically nicotine content of patency; after
ano na ini” known as emesis and  Blood vessel (that OTF and Infuse air into assessment.
informally as tossing supply thalamus patency the tube while Significant
Patient is and internal
in and many other and listening on other
experienci capsule) ruptures
words. Badness can placement the abdomen verbalized
ng and bleeds, with “daw nd
be caused by a lot, of using a
Henriette Jane De Leon BN3A January 21, 2021

discomfort ranging from gastritis high intracranial Nasogastri stethoscope. naman sya
through to brain tumors to pressure c tube Positive miss
non verbal higher intracrane  Blood cytotoxicity Gurgling kasukahon
cue by pressure. and sudden focal sound means it before ko sya
holding internal brain is patent but e feeding”
trauma from GOAL
abdomen without
MET
and hematoma mass gurgling sound
grimacing effect means that is
2. Display
 The hematoma 2. Display has obstruction comfortabilit
Source: disrupts the comfortabilit in the tube. y after
Objective neurons and glia. y because of Placement of assessing the
https://free-
Cues:  results in patent the nasogastric
nursingcareplan.blog
oligaemia, Nasogastric Nasogastric tube. The
Vital spot.com/2011/11/nu
 neuro-transmitter tubing and tube can also NGT’s
signs: rsing-care-plan-for-
release, correct influence the patency was
nausea-and.html
T: 36. 8C  mitochondrial placement. patient to checked and
dysfunction vomit or feel there was
PR: 88
 cellular swelling. nauseous. positive
bpm gurgling
 Thrombin activates
RR: 26 3. Promote sound;
microglia, causes 3. To avoid
cpm Placement of
inflammation and hygiene infection of
nasogastric
edema such as the mouth
BP: 150/90 tube was also
oral caused by
mmHg checked and
hygiene. Nasogastric fixed.
s/s Tube GOAL
O2 sat: Motor weakness MET
99%
Vision Loss 4. Assist 4. A Semi 3. Adapt or get
3. Adapt in client in a Fowler’s used to
Henriette Jane De Leon BN3A January 21, 2021

GCS = 12 Sensory loss Nasogastric comfortabl position Nasogastric

(E4V2M6) Feeding and e position promotes the Feeding.
Sudden headache
prevent at about 45 OTF to pass Patient was
Decreased LOC vomiting. - 90 degree through the reminded to
angle. Nasogastric signal
Nausea significant
Frequent tube by
Vomiting other using
positioning gravity. In
his non
should also addition since
verbal cues if
be done the patient is he has
CVD Bleed Right especially admitted disturbance
Thalamus and Internal that his left because of in his
Capsule side is CVD or nasogastric
weakened. stroke, tube or
frequent gastrointestin
As admitted, NGT was positioning is al system.
inserted; experienced a must to Patient
vomiting after feeding prevent understood
pressure the advised
and nodded
ulcers, blood
Imbalanced Nutrition; as a
pressure
less than body response.
problems,
requirements r/t vomiting GOAL
Chronic pain
aeb presence of 125 ml MET
in an affected
gastric content output Long Term limb,
goals: infections, etc. Long Term
4. Understand, Goals
along with 4. Comprehend
significant along with
other, the the
Henriette Jane De Leon BN3A January 21, 2021

special Dependent Dependent significant

consideratio Interventions: Interventions: other about
ns of the
1. Give 1. Plasil 10 mg consideration
Nasogastric
medication IV is an s for
tube feeding.
s as per antiemtic nasogastric
physician’s medication. It tube.
order. will help ease Significant
nausea and other
vomiting. verbalized
“Sige miss, e
2. Inform 2. This will aid tinluan ko
physician nurses to gid iya baba
para
of the provide more
maiwasan
patient’s interventions
ang
complain ordered by the
impeksyon”.
regarding physician such Significant
nausea and as if OTF other was
vomiting needs to be on also taught
hold on the how
next Feeding important it
time. is to position
patient
especially
during
feeding to
promote
flow of OTF
into the
nasogastric
Henriette Jane De Leon BN3A January 21, 2021

tube. GOAL
MET