Nursing Care Plan Problem # 1: Increased Inracranial Pressure (July 9, 2009)
As se sm ent Subjective Cues: “Nasusuka siya kaninang umaga at hindi dumidilat ang mata nya,” as verbalized ny the mother. Objective Cues: Decreased LOC: 7/15 (July 9, 2009 1:30 PM) •
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Vomiting RR: 16 bpm(July 9, 2009 1:00pm) HR: 72 bpm( July 9, 2009 1:00pm)
Nursing Di Diagnisis & Rationale Ineffective Tissue Perfusion (Cerebral) related to increased intracranial pressure secondary to exudate formation in the subarachnoid space . Rationale: When the body recognizes bacterial presence in the body, it treats it as a foreign substance triggering an inflammatory response. Neutrophils, monocytes, lymphocytes, and other inflammatory cells respond naturally. An exudates made up of bacteria
P lan ni ng After 8 hours of nursing intervention the client’s GCS of 7/15 will not further decrease or will be maintained.
Int er ven ti ons Independent Monitor vital signs every 30 minutes. To
Eva lu ati on Goal Met
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monitor changes in pulse rate, and respiratory rate because low PR and a slow RR are common signs of ICP.(Comer, 2005) Hyperthermia may also cause increased ICP and Hypothermia causes decreased cerebral perfusion pressure (Sparks and Tayor, 2005) •
Assess LOC. Assessing the client’s neurologic status provides baseline data to measure sudden changes
At the end of the shift, client’s GCS improved from a score of 7/15 to a score of 9/15
fibrin, and leukocytes is formed in the subarachnoid space. This exudates accumulates within the CSF which may casue it to thicken. (Ignatayicius, 1995)
which may indicate neurologic deterioration. (LeMone 2008:1541) •
Elevate the head of client’s bed 30 degrees. This promotes venous drainage, which helps to reduce cerebral edema (Sparks and Taylor, 2005)
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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 Subjective Cues: •
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“Nahihirapa n syang huminga dahil sa dami ng plema nya,”as verbalized by father. “Nahihirapa n syang ilabas ang kanyang plema,” as verbalized by the father.
Objective Cues: •
Crackles on lungs upon auscultatio n.
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Use of accessory muscles
Nursing Diagnosis & Rationale Ineffective breathing pattern related to airway obstruction secondary to increased production of secretions.
Rationale: ineffective breathing pattern and shortness of breath due to the ineffective respiration of the chest wall and lung resulting in deprivession infective diaphragmatic movement, airway irritants and obstruction.
Planning After 1 hour of nursing intervention s, the patient will show improvement in breathing pattern as manifested by a normal respiratory rate ranging from 20-30 bpm.
Interventions Independent •
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Goal met
Assess and record After 1 hour of respiratory rate nursing every 30 mins. To interventi detect changes in ons. The breathing patient patterns and showed recognize signs improvemen of respiratory t in compromise breathing (Sparks & Taylor, from an RR 2005;43) Asses ABG levels. of 35 bpm to an RR To monitor of 27 bpm. oxygenation and ventilation status (Sparks & Taylor, 2005;43)
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Evaluation
Auscultate lungs for presence of normal or adventitious breath sounds such as crackles, wheezing, and coarse sounds. The presence of the above sounds may indicate
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RR:35 (July 9, 2009 2:00 pm)
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Fast, shallow respiration s
respiratory distress or accumulation of secretions. (Doenges, 2006;125) •
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 Subjective Cues: “Nilalagnat siya at mattas daw ang temperature niya sabin ng nurse,” as verbalized by father. Objective Cues: •
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Temp: 39.1
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Skin very warm to touch Chills
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Flushed skin CBC result: WBC of 18.29(N:510^9/L) (July 9, 2009)
Nursing Diagnosis & Rationale Hyperthermia related to body’s response to infection and disturbed temperature regulation by the hypothalamus 2 0 to increased ICP. Rationale: Once the organism begins multiplying, neutrophils and/or phagocytic infiltrate into subarachnoid space and forms an exudate. The body’s defenses attempt to control the invading pathogens by walling off the exudates. During the infection process, and when our body defences fight with the organism, an individual may manifest increase in temperature and chills. (Comer, 2005)
Planning At the end of the shift, the client’s temperature will decrease from 39.1 0C to normal range(36.537.20C)
Interventions
Evaluation
Independent Monitor vital signs every 30 minutes. To check changes in client’s temperature and to obtain core temperature (Sparks & Taylor, 2005) Promote surface cooling by removing blankets or extra clothing. May promote heat loss through radiation and conduction (Doenges, 2006) Make sure rapid temperature decrease doesn’t occur. Shivering may result, causing temperature to increase (Lewis, 2007) Perform TSB. •
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Goal partially met After the shift, client’s temperatur e dropped from 39.10C to 38.20C But not within normal limits.
Helps in body heat loss through evaporation and conduction (Doenges, 2006).
Problem #4: Impaired Swallowing Assessment Objective Cues: •
Decreased LOC
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Stuporous
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GCS of 7/15 Depressed cough and (-)gag reflex.
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Nursing Diagnosis & Rationale Risk for Aspiration r/t ineffective swallow reflex 2 0 to decreased level of consciousness.
Rationale: Aspiration can occur under many different circumstances. It is often a complication in individuals of any age when the swallowing or gag reflex is depressed for any reason such as anesthesia, stroke, or in comatose patients. Individuals who eat or drink perhaps take medications when lying down also risk aspiration because the gravitational force is of no value to the moving of food and completely down the esophagus. (Gould, 2007)
Planning After 4 hours of nursing intervention , the client will maintain a patent airway and will not experience aspiration.
Interventions •
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Assess respiratory Goal met status. To detect After 4 signs of possible hours of aspiration such nursing as diminished breath sounds and interventi on, the increased client was respiratory rate able to (Sparks & Taylor, maintain a 2005) Position client in patent airway and High Fowler’s position for about did not experience 30 minutes after aspiration feeding. Correct . positioning prevents regurgitation or aspiration of food. (Ignatayicius, 1995)
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Evaluation
Have suction equipment available at bedside. For quick suctioning in case the client 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 Objective cues: •
Purposeless movement
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Sudden abnormal flexion of the extremities
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Uncontrolle d movement
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Increased ICP
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Brain infection
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CT scan results: communicati ng hydrocephal us
Nursing diagnosis & Rationale High risk for injury r/t seizure activity secondary to cerebral infection/irritation.
Rationale: ICP and seizures are associated with meningitis. Seizures occur secondary to focal areas of the cerebral cortec being irritated by infection (Smeltzer, 2004)
Planning
Interventions
After 30 minutes of nursing intervention , the client will be free from injuries resulting from seizure activity and significant others will be able to verbalize understandin g of factors that contribute to seizure and verbalize their knowledge about seizure precautions.
Independent Side rails up at all times. To prevent from fall in the event of a seizure(Comer, 2005) Educate family members on about safety during seizures, such as: remaining cals; moving client away from furniture or sharp objects; don’t restrain client; be aware that cyanosis may occur for some time; notify physician; may need oxygen; do not attempt to place a stick or padded tongue blade. To provide knowledge on what to do in case of seizure attacks •
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Evaluation Goal Partially met After 30 minutes of nursing interventi on, the client remained free of seizurerelated injuries and the significan t others verbalized knowledge about the contributi ng factors of seizure and the safety precaution on seizure.
(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 & Rationale
Subjective Cues:
Risk for Impaired skin intergrity related to prolonged bedrest secondary to decreased level of consciousness.
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“Matagal na siyang nakahiga kasi hindi siya nakakagalaw ng maayos,” as verbalized by the mother.
Objective Cues: •
Stuporous
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Immobile
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Bedridden
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Decreased LOC
Rationale:When there is bacterial infection in the brain, inflammation, exudation, and WBC accumulation occurs. This causes increased cranial pressure on the brain and causes it to be edematous. When this happens the CSF flow is obstructed and
Interventions
Planning
After 8 hours of nursing interventions, the client’s skin will remain intact and the family members will gain knowledge on the different ways skin breakdown can be prevented.
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Educate the family members about the possible effects prolonged bedrest may have on the skin. Motivates family members to implement a skin care regimen and gives them the knowledge to prevent skin breakdown (Sparks & Taylor, 2005)
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Position the client for comfort and minimal pressure on bony prominences. It reduces the risk for skin breakdown (Lewis,
Evaluation
level of consciousness is affected. Because of decreased LOC, the individual may experience stupor, drowsiness, and may sometimes go into coma. Brain function is decreased in a way that the person may not be in full muscle control (Wong, 2005)
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Explain the therapy to the family members. To encourage compliance (Lewis, 2007)
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Demonstrate massage techniques and explain its purpose. It promotes adequate tissue perfusion (Sparks & Taylor, 2005)
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Help the family members develop a skin care and inspection routine. Discuss the need for good hygiene and the use of nonirritating 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)