Nursing Care Plan

Problem # 1: Increased Inracranial Pressure (July 9, 2009)

Assesment Nursing Diagnisis & Planning Interventions Evaluation

Rationale
Subjective Cues: Ineffective Tissue After 8 Independent Goal Met
• “Nasusuka Perfusion hours of • Monitor vital
siya (Cerebral) related nursing signs every 30 At the end
kaninang to increased intervention minutes. To of the
umaga at intracranial the client’s monitor changes shift,
hindi pressure secondary GCS of 7/15 in pulse rate, client’s
dumidilat to exudate will not and respiratory GCS
ang mata formation in the further rate because low improved
nya,” as subarachnoid space. decrease or PR and a slow RR from a
verbalized will be are common signs score of
ny the Rationale: When maintained. of ICP.(Comer, 7/15 to a
mother. the body 2005) score of
Objective Cues: recognizes Hyperthermia may 9/15
• Decreased bacterial presence also cause
LOC: 7/15 in the body, it increased ICP and
(July 9, treats it as a Hypothermia
2009 1:30 foreign substance causes decreased
PM) triggering an cerebral
• Vomiting inflammatory perfusion
response. pressure (Sparks
• RR: 16
Neutrophils, and Tayor, 2005)
bpm(July 9,
monocytes, • Assess LOC.
2009
lymphocytes, and Assessing the
1:00pm)
other inflammatory client’s
• HR: 72 bpm( cells respond
July 9, neurologic status
naturally. An provides baseline
2009 exudates made up
1:00pm) data to measure
of bacteria sudden changes
fibrin, and which may
leukocytes is indicate
formed in the neurologic
subarachnoid deterioration.
space. This (LeMone
exudates 2008:1541)
accumulates within • Elevate the head
the CSF which may of client’s bed
casue it to 30 degrees. This
thicken. promotes venous
(Ignatayicius, drainage, which
1995) helps to reduce
cerebral edema
(Sparks and
Taylor, 2005)
• Keep client’s
head in neutral
alignment. Keeps
carotid flow
unobstructed,
promoting
perfusion.
Dependent
• Provide oxygen
therapy as
ordered.
Increases
oxygenation.
(Ignatayicius,
1995)
Problem #2: Difficulty of breathing

Assessment Nursing Diagnosis & Planning Interventions Evaluation

Rationale
Subjective Cues: Ineffective breathing After 1 hour Independent Goal met
pattern related to of nursing
• “Nahihirapa airway obstruction intervention • Assess and record After 1
n syang secondary to s, the respiratory rate hour of
huminga increased production patient will every 30 mins. To nursing
dahil sa of secretions. show detect changes in interventi
dami ng improvement breathing ons. The
plema Rationale: in breathing patterns and patient
nya,”as ineffective breathing pattern as recognize signs showed
verbalized pattern and shortness manifested of respiratory improvemen
by father. of breath due to the by a normal compromise t in
• “Nahihirapa ineffective respiratory (Sparks & Taylor, breathing
n syang respiration of the rate ranging 2005;43) from an RR
ilabas ang chest wall and lung from 20-30 • Asses ABG levels. of 35 bpm
kanyang resulting in bpm. To monitor to an RR
plema,” as deprivession oxygenation and of 27 bpm.
verbalized infective ventilation
by the diaphragmatic status (Sparks &
father. movement, airway Taylor, 2005;43)
irritants and • Auscultate lungs
Objective Cues: obstruction. for presence of
normal or
• Crackles on adventitious
lungs upon breath sounds
auscultatio such as crackles,
n. wheezing, and
• Use of coarse sounds.
accessory The presence of
muscles the above sounds
may indicate
• RR:35 (July respiratory
9, 2009 distress or
2:00 pm) accumulation of
• Fast, secretions.
shallow (Doenges,
respiration 2006;125)
s • Place the patient
on high-fowler’s
position.
Positioning helps
maximize lung
expansion and
decrease
respiratory
effort. Maximal
ventilation may
open at electatic
areas and promote
movement of
secretions into
larger airways of
expectoration.
Dependent

• Administer
medications
and/or oxygen.
Problem #3: Fever

Assessment Nursing Diagnosis & Planning Interventions Evaluation

Rationale
Subjective Cues: Hyperthermia related At the end Independent Goal
• “Nilalagnat to body’s response to of the • Monitor vital partially
siya at infection and shift, the signs every 30 met
mattas daw disturbed temperature client’s minutes. To check
ang regulation by the temperature changes in After the
temperature hypothalamus 20 to will client’s shift,
niya sabin increased ICP. decrease temperature and client’s
ng nurse,” from 39.10C to obtain core temperatur
as Rationale: Once the to normal temperature e dropped
verbalized organism begins range(36.5- (Sparks & Taylor, from
by father. multiplying, 37.20C) 2005) 39.10C to
Objective Cues: neutrophils and/or • Promote surface 38.20C
• Temp: 39.1 phagocytic infiltrate cooling by But not
into subarachnoid removing blankets within
• Skin very
space and forms an or extra normal
warm to
exudate. The body’s clothing. May limits.
touch
defenses attempt to promote heat loss
• Chills control the invading through radiation
• Flushed pathogens by walling and conduction
skin off the exudates. (Doenges, 2006)
• CBC result: During the infection • Make sure rapid
WBC of process, and when our temperature
18.29(N:5- body defences fight decrease doesn’t
10^9/L) with the organism, an occur. Shivering
(July 9, individual may may result,
2009) manifest increase in causing
temperature and temperature to
chills. (Comer, 2005) increase (Lewis,
2007)
• Perform TSB.
Helps in body
heat loss through
evaporation and
conduction
(Doenges, 2006).
Problem #4: Impaired Swallowing

Assessment Nursing Diagnosis & Planning Interventions Evaluation

Rationale
Objective Cues: Risk for Aspiration After 4 • Assess respiratory Goal met
• Decreased r/t ineffective hours of status. To detect
LOC swallow reflex 20 to nursing signs of possible After 4
• Stuporous decreased level of intervention aspiration such hours of
consciousness. , the client as diminished nursing
• GCS of 7/15
will breath sounds and interventi
• Depressed Rationale: Aspiration maintain a on, the
increased
cough and can occur under many patent client was
respiratory rate
(-)gag different airway and able to
(Sparks & Taylor,
reflex. circumstances. It is will not maintain a
2005)
often a complication experience • Position client in patent
in individuals of any aspiration. High Fowler’s airway and
age when the position for about did not
swallowing or gag 30 minutes after experience
reflex is depressed feeding. Correct aspiration
for any reason such positioning .
as anesthesia, prevents
stroke, or in regurgitation or
comatose patients. aspiration of
Individuals who eat food.
or drink perhaps take (Ignatayicius,
medications when 1995)
lying down also risk • Have suction
aspiration because equipment
the gravitational available at
force is of no value bedside. For
to the moving of food quick suctioning
and completely down in case the
the esophagus. client
(Gould, 2007) experiences
 aspiration.
• Make sure feeding
tube is in correct
position before
giving OF feeding.
This is to
prevent
aspiration
(Gould, 2007)
Dependent
• Insert OGT as
ordered. An OGT
may be inserted
to gain bring
food to stomach
in the case of
impaired
swallowing and
depressed gag
reflex
(Ignatayicius,
1995)
Problem #5: Risk for seizures

Assessment Nursing diagnosis & Planning Interventions Evaluation

Rationale
Objective cues: High risk for injury After 30 Independent Goal
• Purposeless r/t seizure activity minutes of • Side rails up at Partially
movement secondary to cerebral nursing all times. To met
• Sudden infection/irritation. intervention prevent from fall
abnormal , the client in the event of a After 30
flexion of Rationale: ICP and will be free seizure(Comer, minutes of
the seizures are from 2005) nursing
extremities associated with injuries • Educate family interventi
meningitis. Seizures resulting members on about on, the
• Uncontrolle
occur secondary to from seizure safety during client
d movement
focal areas of the activity and seizures, such remained
• Increased cerebral cortec being significant free of
as: remaining
ICP irritated by others will seizure-
cals; moving
• Brain infection (Smeltzer, be able to client away from related
infection 2004) verbalize furniture or injuries
• CT scan understandin sharp objects; and the
results: g of factors don’t restrain significan
communicati that client; be aware t others
ng contribute that cyanosis may verbalized
hydrocephal to seizure occur for some knowledge
us and time; notify about the
verbalize physician; may contributi
their need oxygen; do ng factors
knowledge not attempt to of seizure
about place a stick or and the
seizure padded tongue safety
precautions. blade. To provide precaution
knowledge on what on
to do in case of seizure.
seizure attacks
 (Sparks & Taylor)
• Explain the
possible factors
that may lead or
contribute to
seizure. To make
them understand
the disease
process of the
patient(Sparks &
Taylor, 2006)
Dependent
• Administer Drugs
as ordered. To
prevent
convulsion and
manage seizures.
Problem #6: Prolonged bedrest/ immobility

Assessment Nursing Diagnosis Planning Interventions Evaluation

& Rationale

Subjective Cues: Risk for Impaired After 8 hours • Educate the

skin intergrity of nursing family members
• “Matagal na related to interventions, about the
siyang prolonged bedrest the client’s possible effects
nakahiga secondary to skin will prolonged bedrest
kasi hindi decreased level of remain intact may have on the
siya consciousness. and the family skin. Motivates
nakakagalaw members will family members to
ng maayos,” gain knowledge implement a skin
as on the care regimen and
Rationale:When
verbalized different ways gives them the
there is bacterial
by the skin breakdown knowledge to
infection in the
mother. can be prevent skin
brain,
inflammation, prevented. breakdown (Sparks
Objective Cues:
exudation, and WBC & Taylor, 2005)
• Stuporous accumulation
• Position the
occurs. This
• Immobile client for
causes increased
comfort and
cranial pressure
• Bedridden minimal pressure
on the brain and
on bony
causes it to be
• Decreased prominences. It
edematous. When
LOC reduces the risk
this happens the
for skin
CSF flow is
breakdown (Lewis,
obstructed and
level of 2007)
consciousness is
affected. Because • Explain the
of decreased LOC, therapy to the
the individual may family members.
experience stupor, To encourage
drowsiness, and compliance
may sometimes go (Lewis, 2007)
into coma. Brain
• Demonstrate
function is
massage
decreased in a way
techniques and
that the person
explain its
may not be in full
purpose. It
muscle control
promotes adequate
(Wong, 2005)
tissue perfusion
(Sparks & Taylor,
2005)

• Help the family

members develop a
skin care and
inspection
routine. Discuss
the need for good
hygiene and the
use of non-
irritating soap
and help them
urecognize and
report signs of
breakdown such as
redness and
discoloration. A
daily program of
inspection and
skin care will
protect the
patient’s skin
integrity (Sparks
& Taylor, 2005)