Nursing Care Plan


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Medical Diagnoses:Ineffective tissue perfusion: cerebral related to altered LOC, unilateral neglect and impaired urinary elimination


1.      Ineffective tissue perfusion: cerebral related to altered LOC

·         General response; sluggish pupil response, only responds to pain in a non-purposeful manner

·         Abnormal lab values

·         Nasal intubation

·         Grand mal seizures

7. Unilateral neglect related to ischemic brain injury.

·         Previous CVA with left-sided residual

·         Altered LOC

·         Grand mal seizures

·         Left- sided edema

2. Ineffective airway clearance related to altered LOC

·         Nasal intubation

·         Generalized response

·         Grand mal seizures

·         Abnormal lab values

·         Secretions

4. Impaired urinary elimination related to impairment in neurologic sensing and control.           

·         LOC- generalized response

·         Foley catheter

·         Chucks

Chief Complaint:  A 64 year old black female unresponsive because of an ischemic injury to the brain related to uncontrolled blood sugar levels.

 

Priority Assessment: Monitor vitals and LOC.  Monitor labs and blood glucose levels.  Practice isolation precautions and standard precautions to prevent infection.  Monitor skin breakdown and turn q 2 hours.  Monitor I’s and O’s and nutrition intake.  Monitor HOB and maintain at 30 degrees. 

3. Impaired skin integrity related to prolonged immobility

·         Skin tear on coccyx

·         Blister on right arm

·         2+ pitting edema right hand

·         LOC- generalized response

·         Foley catheter

·         Fecal management

·         Diabetes

·         Nutrition management

5. Bowel incontinence related to impairment in neurologic sensing and control and changes in nutritional delivery methods.

·         Fecal management

·         Chucks

·         Pepcid-watery stools

8. Interrupted family processes related to health crisis

·         Discussing the quality of life the pt. will have following prognosis.

6. Risk for infection related to invasive procedures

·         Rt. Upper arterial picc

·         Nasal intubation

·         Dobhoff tube

·         Foley catheter

·         Fecal management

·         LOC- generalized response

·         diabetes


NANDA Diagnostic Statement: Ineffective tissue perfusion: Cerebral related to alter LOC AEB sluggish pupil response, poor withdraw and abnormal ABG’s.

 

Behavioral Outcome / Goal: Pt. will demonstrate intact neurologic status and normal vital signs, respiratory patterns and normal lab values by February 18, 20xx.


Nursing Interventions:

 

1.      Monitor and interpret pt.’s lab work, hemodynamics and ICP.

2.      Treat the pt.’s seizure activity immediately.

3.      Reposition pt. at least every 2 hours. Maintain alignment with pillows and monitor positioning around lumbar area.  Prevent skin breakdown and joint integrity.

4.      Perform a neurologic assessment every 4 hours.

5.      Monitor pt.’s vitals every 4 hours.

6.      Maintain pt.’s head of the bed at 30 degrees at all times.

7.      Provide the pt. good oral care every 4 hours.

8.      Monitor pt.’s I’s and O’s and tube feedings._______________________

Rationale:

 

1.       Determines efficacy of therapy and need for alternation of plan of care. (Cox’s Clinical, pg: 398)

2.       This can decrease functional and cognitive disability if implemented as soon as a seizure occurs. (Smeltzer, pg: 1915)

3.       Help stimulate circulation.  Alignment helps prevent pain malpractice and enhances comfort.  (Cox’s Clinical pg:488)

4.       Monitors levels of responsiveness or consciousness. (Smeltzer, pg: 1859)

5.       The circulatory status is monitored to ensure adequate perfusion to the body and brain. (Smeltzer, pg: 1859)

6.       Elevating the head of the bed prevents aspiration. (Smeltzer, pg:1860)

7.       Recent evidence shows that a routine of oral care decreases ventilator-associated pneumonia. (Smelzter, pg: 1862)

8.       Fluid balances have to be maintained to ensure pt. doesn’t get overloaded or deficit and nutrition is needed for recovery. (Smeltzer, pg: 1862)______________________________

Client Response:

 

1.      Monitored q 8 hours.

2.      Pt. is prescribed Cerebyx 70 mg, IV every 8 hours and Depacon 100 ml/hr, IV BID.

3.      Shifted pt. q 2 hours. Pt. was unresponsive during stimulating and repositioning.

4.      Unresponsive to voice and generalized response to pain with sluggish pupil response.

5.      Radial and pedal pulses present. Blood pressure 159/96 and heart rate 118.

6.      Pt.’s head of bed is positioned at 30 degrees to maintain a good airway.

7.      Physician prescribed a sage oral care kit q 4 hours.

8.      Adequate amounts of urine output and tube feedings are being digested.___________________

Summarize impressions of client progress toward outcomes / problem resolution: Pt. is unresponsive to verbal stimulation and generalized responsive to painful stimulation.  The pt. is experiencing an infection because the hemoglobin, hematocrit, blood glucose levels and WBC’s are above normal value. Palliative came and spoke with the family on the poor quality of life the pt. will now have because of the extensive damage her multiple strokes caused.  The pt.’s life expectancy is limited also because of the acuity of the pt.  Next step is a tracheostomy to maintain an airway.  Palliative also discussed the care the pt. will now need and the options that are available for the pt. and the family.________________________________________________________________________________________________________________


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