NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Gen. Objective: Independent:

Objective Cues: 3. Risk for ineffective cerebral Edema & hematoma Promote or maintain 1. Assess neurologic status & A change in level of consciousness
craniectomy was perfusion related to edema formation causes effective cerebral vital signs frequently & compare is the first sign of an
performed for formation or bleeding after compression of nerves & perfusion. with baseline values. increasing intracranial pressure.
decompression craniectomy or due to blood vessels resulting to 2. Elevated head of bed to 30 Elevation facilitates venous
and evacuation hematoma formation. altered blood flow; these Specific Objectives: degrees. drainage and reduces edema.
of comminuted occupies normal tissue After the nursing 3. Maintain head & neck in This facilitates venous
fracture spaces leading to interventions have been neutral alignment. drainage and reduces edema.
a comminuted compression. employed, 4. Change position slowly. Rapid changes in position
fracture on the Compression alters blood flow the patient will: increase cerebral blood flow and
frontal area resulting to ischemia, and 1. Have an ICP of less pressure.
A drain has been necrosis may occur than 15 mmHg 5. Avoid a Valsalva maneuver. Straining during coughing,
held in place destroying major 2. Neurologic movement in bed, or moving
to promote blood functions. assessment and vital bowel increases ICP.
drainage and signs are at baseline 6. Monitor intake & output Excess fluids can promote edema
prevent possible values or improved. frequently. dehydration can decrease
hematoma 3. No manifestations of cerebral arterial flow.
formation increased ICP. 7. Suction airway as needed. Routine suctioning not
4. Body temperature advised because it stimulates
less than 38.5C. cough and increases ICP;
however, sputum plugs cause
retention of carbon dioxide and
need to be removed
because carbon dioxide
increase cerebral blood flow and
pressure.
8. Administer steroids as ordered. This reduces cerebral edema.
9. Administer anti - epileptic Seizures are a common
drug as ordered. sequelae of brain surgery.
10 Observe for signs of Hematoma formation causes
hematoma formation. compression to brain tissues
(dangerous complication of brain leading to ischemia and
surgery secondary to VA.) necrosis.

But could be given by body requirements realted to
cotton water. inability to ingest/ digest food or
absorb nutrients; N & V, NPO
O: Patient is weak, status & nasogastric suctioning &
restless, pallor, loss of appetite as evidenced by
showing expressions reported inadequate food intake
of difficulty with her less than RDA, lack of interest in
situation. food "waray gana pagkaon,"/
aversion to eating & perceived
inability to digest food.
4. RISK for infection related to
inadequately primary defenses
(weak body), altered peristalsis,
change in pH secretions,
nutritional deficiencies & stasis of
body fluids; chronic diseases,
very essential since we can't
survive without the two.
Gradual decrease of food
intake would lead to body
failure.
Body weakness would
further lead to infections.
3. Patient will be able to 1. Assess the over all nutritional
demonstrate progress- status of the client by checking her previous data.
ive weight gain toward daily weights, tissue integrity
goal with normalization & presence of adequate body fat
of laboratory values; and muscle mass.
Demonstrate behaviors, 2. Encourage client to choose To stimulate appetite.
lifestyle changes to foods that are appealing.
regain and or maintain 3. Avoid foods that causes So as not to cause intestinal
appropriate weight. intolerances/ gastric motility problems.
(gas - forming foods, hot & spicy)
4. Limit fiber/ bulk. Since they can lead to early
satiety.
5. Promote pleasant, relaxing To stimulate proper appetite/
environment. enhance intake.
6. Limiting fluids hours prior to So as not to cause early
meal satiety.
7. Weigh weekly & prn. To monitor effectiveness of
care.
DISCHARGE PLANNING:
1. Emphasize importance of well
balance, nutritious intake.
2. Provide info regarding
individual needs & ways to meet
these needs within financial
constraints.
4. Achieve timely 1. Demonstrate lifestyle changes For personal growth of the
healing. Be free of signs to promote safe environment. person.
of infection 2. Cleanse insertion sites daily & To prevent sepsis.
Be afebrile. prn with solution.
3. Encourage early ambulation, For mobilization of gastric
deep breathing, coughing, secretions.
position changes.
DISCHARGE PLANNING:
1. Explain the importance of proper
 hygiene especially hand washing.

5. Ineffective breathing pattern Normal range of value for 5. The client will maintain 1. Maintain calm attitude, while To as to maintain and improve
O: RR 30 bpm. related to abdominal pain/ RR is 15 - 20 bpm. an effective breathing dealing with client to limit anxiety. rapport.
Patient having deep,tenderness as evidenced by RR 30 pattern as evidenced by 2. Assist client in use of relaxation So as to relax the client from
shallow, irregular bpm, anxiety/ decreased energy, RR within normal limits, techniques. the tension and anxiety she is
breathing. fatigue. relaxed respiratory effort suffering.
Demonstrate approp.
coping behaviors.
S: Patient uttered, 6. Anxiety related to change in Anxiety is a vague feeling 6. The client will express 1. Assess the client's level of To determine what interventions
"Tangala na ini na health status, change in of apprehension as to what and demonstrate anxiety by listening and observing. are suitable for the client.
adi tak may irong." environment, fear of pain returning will happen next. It is a normal decreasing 2. Reassure the client and To let the client feel secured,
& irritation brought about by the defense mechanism of the manifestations of acknowledge that the unknown is that she is not alone.
O: Fatigue, touchi NGT tube attached. body. anxiety as evidenced of frightening.
the NGT tube which displaying behavior 3. Allow significant others to
she wants to be associated with remain with the client.
removed. relaxation.

NAME: ROOM & BED #:

AGE/SEX: WARD:
CHIEF COMPLAINT: ATTENDING PHYSICIAN:

Prepared by: Submitted to:

DONN ED MARTIN A. ABRIL MR. ROBERT PONTIAN AGNER, R.N.

RTRMF - CN Student Nurse Clinical Instructor
EVRMC
15-Nov-05