Nursing Care Plan ASSE ASSESS SSME MENT NT
SCIE SCIENT NTIF IFIC IC
INFERENCE
PLANNING
INTERVENTION
Subjective:
EXPLANATION Impaired physical
Neuromuscular
Short term
•
mobility related to
disorders affect the
”Hindi ko maigalaw
neuromuscular
nerves that control
After 4 hours, the
ang aking kaliwang
impairment
the voluntary
patient verbalize
muscles. Voluntary
understanding
hindi ko rin maigalaw
muscles are the
situation or risk
ang kaliwa kong
ones that can be
factors and
paa.”
controlled, like in the
individual treatment
arms and legs. The
regimen and safety
nerve cells, also
measures
kamay at medyo
Objective:
called neurons, send Left hemi paralysis
Long term
control these
After 4 months of
Limited range of
muscles. When the
continuous ,effective
motion (ROM)
neurons become
•
EVALUATION
To note changes
After 4 hours of
and for baseline
nursing intervention
comparison.
the patient was able to verbalize
•
To be informed
understanding
diagnosis that
about the
situation or risk
contributes to
situations that may factors and
immobility
restrict
individual treatment
movements
regimen and safety
Determine the
•
measures •
the messages that
Monitor V/S
RATIONALE
Encourage and
•
The longer the patient remains
After 4 months of
ambulation and other
immobile the
continuous ,effective
ADLs when possible.
greater the level of and collaborative
and collaborative
Assist with each
debilitation that
nursing
unhealthy or die,
nursing
initial change:
will occur
interventions, patient
Functional level:
communication
interventions,
dangling, sitting in
was able to maintain
level 2-requires help
between the nervous patient will
chair, ambulation
position and function
facilitate early
from another person.
system and muscles
maintain position,
breaks down. As a
function and skin
result, the muscles
integrity
and skin integrity as •
Perform passive or
•
Exercise promotes evidenced by the
active ROM
increased venous
absence of
weaken and waste
exercises to all
return, prevents
contractures,
away. The
extremities
stiffness, and
footdrop, decubitus
weakness can lead
maintains muscle
and so forth
to twitching, cramps,
strength and
aches and pains,
endurance
and joint and movement
•
Turn and position
•
This optimizes
problems.
every 2 hours or as
circulation to all
Sometimes it also
needed.
tissues and
affects heart function
relieves pressure.
and ability to breathe. Many
•
Provide safety
•
To provide safety
neuromuscular
measures(side rails,
and reduce the
diseases are
using pillow to
risk of pressure
genetic, which
support body part)
ulcers
means they run in families or there is a mutation in your
genes. Sometimes,
•
an immune system
Massage back and
•
bony prominences
It provides comfort to the patient and
disorder can cause
promotes good
them. Most of them
circulation
have no cure. The goal of treatment is
•
Consult with physical
•
To develop
to improve
or occupational
individual exercise
symptoms, increase
therapist as
therapy or
mobility and
indicated
program
lengthen life.
Reference: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=35
ASSESSMENT
SCIENTIFIC EXPLANATION
INFERENCE
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective:
Constipation related
A decrease in a
After 8 hours, the
Assist in
After 8 hours, the
“Hindi ako
to insufficient physical
person's normal
patient will establish
color, consistency,
identifying
patient was able to
mapadumi.”
activity
frequency of defecation,
or return to normal
frequency and
causative and
establish or return to
patterns of bowel
amount
contributing
normal patterns of
Objective:
accompanied by
functioning
factors and
bowel functioning as
Abdominal pain,
difficult or
appropriate
evidenced by easy
urgency
incomplete passage
interventions
passage of
•
Determine stool
•
of stool and/or Altered bowel
passage of
sounds
excessively hard,
Left Hemi paralysis
long, round, and •
Auscultate
•
Bowel sounds are
smooth brown-
generally
shaded stool with a
dry stool. A lack of
decreased in
texture similar to
physical activity can
constipation
creamy peanut
bowel sounds
lead to constipation. Limited ROM
For example,
butter •
Encourage
•
Assists in
constipation often
increased fluid
improving stool
Constipated for five
occurs after an
intake, 2500-3000
consistency
days
accident or during
ml/day within
an illness when one
cardiac tolerance
must stay in bed and cannot exercise. Lack of
•
Encourage to eat high-fiber rich
•
To enhance easy defecation
physical activity is
foods
thought to be one of the reasons
•
•
Recommend
Decrease gastric distress and
constipation is more
avoiding gas-
abdominal
common in older
forming foods
distention
people. Moreover, increased physical activity is more likely
•
•
Assist in
to stimulate bowel
perianal skin
motility and improve
condition frequently,
the symptoms of
noting changes or
constipation.
beginning
Prevents skin excoriation and breakdown
breakdown •
•
Discuss use of
Facilitates defecation when
stool softeners, mild
constipation is
stimulants, bulk-
present
forming laxatives, or enemas as indicated. Monitor
effectiveness •
•
Identify factors
Constipation is a common side
(e.g., medications,
effect of many
bed rest, diet) that
drugs including
may cause or
narcotics and
contribute to
antacids.
constipation. Evaluate medication profile for gastrointestinal side effects. •
Fiber absorbs water, which adds
•
Consult dietitian
bulk and softness
to provide well-
to the stool and
balanced diet high
speeds up
in fiber and bulk
passage through the intestines
Reference: http://www.med.umich.edu/1libr/aha/umconstipation.htm
ASSESSMENT
DIAGNOSIS
SCIENTIFIC
PLANNING
INTERVENTION
SUBJECTIVE:
Impaired adjustment
EXPLANATION Inability to modify
Short Term Goal
Independent
“ayoko kumain ng
related to health
lifestyle in a manner
After 4 days of
•
walang lasa”
status requiring
consistent with a
nursing intervention,
monitored and
change in lifestyle
Vital signs
RATIONALE
EVALUATION After 4 days of
•
For baseline
nursing interventions
comparison
the goal is met
change in status.
there will be an
recorded. BP
through participation
OBJECTIVE:
The objective of
increase interest and
monitored regularly
and demonstration of
>pale to pinkish
nursing care for
participation on the
conjunctiva and lips
hypertensive patients demonstration of self
>weak looking
lifestyle changes •
Assist the patient in
•
These risk factors
focuses on lowering
care and will initiate
identifying
have been shown
and controlling the
lifestyle changes that
modifiable risk
to contribute to hypertension
blood pressure
will permit adaptation
factors like diet
>fair appetite,
without adverse
to present medical
high in sodium,
selective with food
effects and without
situation
saturated fats and
preferences
undue cost. To achieve these goals,
cholesterol
BP-130/90 mmHg
the nurse must
•
Instruct and
•
This will promote
support and teach
emphasize
trust and will on
the patient to adhere
necessary care and
the patient to
to the treatment
lifestyle changes
adhere to such
regimen by
that will enhance
activities that will
implementing
her recovery.
enhance fast
necessary lifestyle
recover
changes like avoidance of foods
•
Plan necessary
•
Planning with the
high in sodium and
care and
relative will add
fats and taking
assistance in ADLs
more cooperation
medications as
with the relative
of the patient
prescribed. •
Emphasize the
•
importance of
This will lower the patient’s BP
adequate rest
•
Emphasize the
•
Hypertension
importance of
needs medications
adherence to
to maintain the BP
medications
•
Provide an open
in its normal range
•
Expression of
environment
feelings
encouraging
concerning
communication
impaired function is dealt with realistically
Reference: http://www.medicinenet.com/high_blood_pressure/article.htm
DRUG STUDY
Name of Drug
Classification
Indications
Side Effects
Contraindications
Nursing
Monitoring
Responsibilities
Parameters
•
Generic Name:
Mannitol
Miscellaneous Fluids
•
or Diuretics
Reduction of
•
Dizziness
•
Hypersensitivity
increased
•
Headache
•
Severe renal
condition before
signs, CVP, and
•
Convulsions
disease
therapy and
urine specific
•
Blurred vision
Severe
regularly
gravity
•
Diuresis
dehydration
thereafter to
Pulmonary
monitor drug
manifestations of
congestion
effectiveness
electrolyte
Assess for
imbalance
intracranial •
Brand Name:
Osmofudin 20%
•
Action
pressure
-increase osmotic
associated with
pressure of
cerebral edema
Dry mouth
•
Assess patient’s
Route and
glomerular filtrate
Frequency:
which inhibits tubular
increased ocular
re-absorption of
pressure
possible drug
IV q4
water and •
•
•
•
Dose:
100 cc
•
Reduction of
•
Loss of hearing
•
•
•
•
Monitor vital
Monitor
Assess BP before
Promotion of
induced adverse
and during the
electrolytes and
diuresis in the
reactions.
therapy with
increases urinary
prevention and/or
Assess patient for
patient lying,
output
treatment for
possible drug
standing and
oliguria or anuria
induced adverse
sitting, orthostatic
due to acute renal
reactions.
hypotension can
Teach patient to
occur rapidly.
•
failure
•
•
recognize and immediately report adverse reactions
•
Asses patient’s and family’s knowledge of drug therapy
Name of Drug Generic Name: •
Classification CNS stimulants or
Citicholine
Neurotonics
Indications CVA in acute and
•
recovery phase. Signs and
•
Brand Name:
Action
symptoms of
Cytidine Diphosphate -A derivative of Choline
involved in the •
Route and
biosynthesis of
Frequency:
lecithin. It is claimed
IV q12 •
Dose:
1 gm
cerebral
choline and cytidine
to increased blood flow and oxygen consumption.
insufficiency. •
•
Side Effects Shock
•
Contraindications Hypertonia of the
•
•
Hypersensitivity
parasympathetic
•
Hypotension
nervous system
•
Insomnia
•
Stimulates
•
Nursing
Monitoring
Responsibilities Evaluate patient
Parameters Monitor vital signs
•
medical history •
Pregnancy and lactation
•
Assess allergic reaction like GI
condition
disturbances
Should not be administered to
Recent cranial
action and
patient with
trauma
fleeting and
hypertonia of the
Parkinson’s
discreet
parasympathetic
disease
hypotension
nervous system •
•
Assess patient
parasympathetic
effect
•
Caution that large doses could aggravate
increase in cerebral blood flow in episodes of persistent intracranial hemorrhage. •
Teach patient to gain benefits and not to miss any dose
Name of Drug
Classification
Indications
Side Effects
Contraindications
Nursing
Monitoring
Responsibilities
Parameters
•
Generic Name:
Simvastatin
Cardiovascular
•
Statins
To reduce LDL
•
Abdominal pain
cholesterol,
•
Constipation
to any component
fat , protein,
phophokinase
•
Flatulence
of the
carbohydrates;
levels due to
•
Insomnia
preparations
nutritional
possibility of
•
Headache
Children and
analysis should
myopathy; serum
lactation
be completed by
cholesterol
Active liver
dietitian before
disease
treatment is
triglycerides,
Unexplained
initiated
cholesterol
Assess liver
baseline and
apolipoprotein •
Brand Name:
Altovast
Action
beta and
-Inhibits HMG-COA
triglycerides
reductase enzyme, •
Route and
which reduces
Frequency:
cholesterol
Oral Od
•
cholesterol in the
Dose:
40 mg
•
Rashes
•
Dizziness
•
Muscle cramps
treatment of
production
hyperlipidaemias •
•
To increase HDL
•
•
•
•
Hypersensitivity
•
Assess nutrition:
•
•
Monitor creatinine
Monitor
Coronary heart
persistent
disease
elevations of
function tests
throughout
serum
prior to therapy
treatment
transaminases
and periodically
•
thereafter •
Evaluate therapeutic response and adverse reactions on a regular basis
•
Assess
knowledge or teach patient proper use
Name of Drug Generic Name: •
Classification Cardiovascular drugs
Imidapril
“antihypertensive”
•
Brand Name:
Vascor
Action -inhibits angiotensin
Indications Treatment of
•
hypertension
Side Effects Dry cough
•
•
Route and Frequency:
angiotensin II
Oral OD
Dose:
50 mg
and reduction of vascular resistance
Monitoring
Responsibilities Establish
Parameters Monitor blood
•
•
Headache
known
baselines in
•
Rash
hypersensitivity to
renal, liver
•
Palpitation
angiotensin
function tests
orthostatic
•
Fatigue
converting
before therapy
hypotension
•
Discomfort in the throat
•
Monitor bp,
•
Check for edema
or with history of
•
Asses for patient
electrolytes
allergic reactions
during the firs 2
Advise patient to
weeks of therapy
edema •
studies
enzyme inhibitors
angioneorotic
resulting in dilation of peripheral vessels
•
•
Nursing
•
converting enzyme; reduction of
Contraindications Patients with
•
•
Monitor
Pregnancy and
avoid potassium,
lactation
salt substitutes
studies and
Teach patient
symptoms
•
how to take Bp
•
Monitor renal
and normal readings for age group
Nursing Name of Drug Generic Name: •
Classification Cardiovascular drugs
Clonidine
“Centrally-acting
all grades of
drugs”
hypertension with
•
Drowsiness
the exception of
•
Dry mouth
•
Headache
•
Fatigue
•
Action
HPN due to
-stimulates central-
phaeochromooyto
Route and
alpha adrenergic
ma
Frequency:
receptors to inhibit
Oral OD
•
•
Brand Name:
Catapres
•
Indications Management of
Dose:
75 mcg
•
Prophylactic
Side Effects Local skin
•
Contraindications Responsibilities Hypersensitivity to Assess pain,
•
irritation
•
•
•
•
Parameters Monitor baselines •
clonidine
location, intensity,
for renal, liver
Sick sinus
character,
function test
syndrome
alleviating,
before therapy
aggravation
begins
factors, baseline
Anorexia Anxiety
Monitoring
•
•
Monitor BP,
and frequency
standing, sitting,
Perform blood
supine, mental
sympathetic
treatment of
studies,
status, and heart
cardioaccelareators
migraine or
neorophils,
rate.
and vasoconstrictor
recurrent
decreased
centers
vascular
platelets
treatment of
•
Perform renal
migraine •
studies
For relief of
•
cancer pain
Assess Bp and apical pulse before initial dose
•
Note allergic reactions
NAME OF DRUG
CLASSIFICATION
INDICATIONS
Generic Name:
Gastrointestinal /
•
Ranitidine
Brand Name:
I.V
CONTRAINDICATIONS
NURSING
MONITORING PARAMETERS Monitor AST,
Used in
•
Bradycardia
Hypersensitivity
RESPONSIBILITIES Use caution in
hepatobiliray Drugs”
management of
•
Headache
History of acute
presence of renal
ALT, Serum
H2 Receptor
gastrointestinal
•
Fatigue
porphyria
or hepatic
creatinine, signs
Antagonists”
(GI) disorders.
Long-term therapy
impairment.
and symptoms of
Assess for
peptic ulcer
potential for
disease, occult
Zantac
Route:
SIDE EFFECTS
•
Prophylaxis of
•
Depression
Rashes
Constipation
Mechanism of
GI hemorrhage
Action:
from stress
interactions with
blood with GI
ulceration and in
other
bleeding.
Inhibits histamine at H2 receptor site
patients at risk of
pharmacological
Frequency:
in the gastric
developing acid
agents patient
function to
q 12
parietal cells, which
aspiration during
may be taking.
correct dos.
inhibits gastric acid
general
Evaluate results of
Monitor renal
Dose: 50 mg
secretion.
anesthesia.
laboratory tests, therapeutic effectiveness.
