NURSING CARE PLAN Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation evacuation of epidural and subdural hematoma, JP drain (0/0/0) Subjective/Objective cues: Subjective cues: None-with ET tube attached to mechanical ventilator Objective cues: With pupillary size of 4 mm on right eye, 2 mm on left eye, both eyes with negative reaction to light Muscle grade of 1/5 for slight muscle contraction on all extremities, no joint motion. With GCS of 6 (best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs
Nursing Diagnosis with Etiology Ineffective Cerebral Tissue Perfusion related to the interruption of the blood flow to the brain.
Goals of Care Interventions General/Specific General: Independent: Within 2 weeks of medical Assessment and nursing interventions, interventions, Assess mental client will be able to status and improve level of changes in the consciousness. level of consciousness Specific: Within 1 day of medical and nursing interventions, interventions, client will be able to Therapeutic manifest: Position client in Improve/Stable low-fowler’s low-fowler’s level of position (30 consciousness degrees) Improve/Stable GCS score Avoid extreme No pupillary rotation of the changes, seizures, neck widening of pulse pressure, irregular respirations, hypotension and bradycardia. Avoid extreme hip flexion
Rationale
Evaluation
To check for affected cranial nerve functions in the brain (for GCS); check for cerebral hypoperfusion and hypoxia.
GCS of 5 (best eye opening-1, none; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)
Help venous drainage from the brain and promote brain expansion. This will compress the jugular veins leading to an increased intracranial pressure. Increase in intraabdominal and intra-thoracic pressure leading to increased intracranial
Patient is placed in lowFowler’s position; made comfortable in bed and adjusted pillows Patient is monitored frequently; positioned head and neck cautiously and placed a pillow on side for support Patient is repositioned cautiously and provided with pillows for support
to pain) Babinski reflexpositive, and oculocephalic reflex-negative
pressure.
Maintain airway
patent
Prevents build up of secretions leading to increase in carbon dioxide and intracranial pressure.
ET tube placement is monitored if securely attached to patient at the appropriate level of 21 cm; suctioned frequently for secretions
Dependent:
Administer medications such as diuretics (e.g. Mannitol) and anticonvulsants (e.g. Amlodipine, Verapamil)
Mannitol 75 cc was Diuretics are given intravenously to used and needed patient; to decrease antihypertensives such cerebral edema Amlodipine 20 mg per tablet and Verapamil 10 and mg per tablet was also anticonvulsant given to patient medications
Collaborative:
Review oximetry
pulse
Restore maintain balance
or fluid
Hypoxia is associated with reduced cerebral tissue perfusion.
Oxygen saturation patient ranges 98-99%
It maximizes cardiac output and prevents decreased cerebral perfusion associated with hypovolemia.
With IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient, with a rate of 21 drops per minute
Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0) Subjective/Objective cues: Subjective cues: None- with ET tube attached on mechanical ventilator Objective cues: Adventitious breath sounds heard at left anterior lung such as ronchi and wheezing Presence of whitish, tenacious secretions approximately 20 cc Decreased level of consciousness (GCS of 6: best eye openingopens to pain; verbal response1 with ET attached to VR; motor response3, flexes arms and extension of legs to pain)
Nursing Diagnosis with Etiology Ineffective airway clearance maybe related to hypoventilation secondary to brain stem injury
Goals of Care Interventions General/Specific General Independent Within 1 week of m edical Assessment and nursing intervention, Assess client will be able to respiration and mobilize secretions. breath sounds, noting rate and Specific sounds (e.g. Within 1 day of medical tachypnea, and nursing stridor, crackles, interventions, client will wheezes) be able to manifest: Clear breath Evaluate sounds cough/gag reflex Decreased and swallowing secretions ability
Rationale
Assess airway for patency
Assess changes in mental status
These signs and symptoms are indicative of respiratory distress and/or accumulation of secretions.
To determine ability to protect own airway
Maintaining the airway is always first priority, especially in cases of trauma.
Lethargy and somnolence are late signs
Evaluation
Respirations range between 16-21 breaths per minute, regular in rate and rhythm; adventitious breath sounds heard over left anterior lung, including ronchi and wheezing sounds Patient exhibits swallowing and gag reflexes; with absent cough reflex Placement of ET tube on patient is monitored frequently at the appropriate level of 21 cm; suctioned frequently for presence of secretions. Patient is GCS 5 (no eye opening-1, with ET tube attached-1, and flexes arms and extends legs to painful stimuli-3)
Note presence of sputum, assess quality, color, amount, odor and consistency.
Therapeutic Elevate head of bed and reposition every 2 hours and as needed.
Routinely check the patient’s position so he does not slide down in bed.
Use humidifier.
Institute suctioning of the airway.
Abnormalities maybe a result of infection. A sign of infection is discolored sputum. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments.
with whitish, tenacious secretions noted upon suctioning of the mouth and ET tube, approximately 20 cc
This prevents abdominal contents from pushing upward and inhibiting lung expansion.
Patient is monitored frequently; with slight elevation of the foot part to prevent sliding down the bed.
This loosens secretions and facilitates the removal.
Patients VR set-up cmes with a humidifier; monitored frequently from getting used up
Patient was repositioned every two hours, made comfortable in bed while adjusting pillows; provided with chest physiotherapy upon change of position
is suctioned Helps clear Patient frequently for presence secretions. of secretions
Dependent Administer medications (e.g. antibioticsLevofloxacin, Vigocid; mucolytic agents, bronchodilatorsSalbutamol) as ordered, noting effectiveness and side effects.
Collaborative Check and monitor VR setup and patient’s response.
These promote clearance of airway secretions and bronchodilation decreases airway resistance.
Patient was given ILN Salbutamol 1 nebule via face mask; with respiratory rate of 17-21 breaths per minute, regular, non-labored; with no side effects such as hypotension or bradycardia.
The basis for setting every parameter of the ventilator depends on the patient. Maintaining the correct settings for every parameter ensures the proper ventilation to the patient.
With ET tube at 21 cm attached to patient connected to a functional ventilator; with VR set-up of: tidal volume-450 ml, peak flow-50, back up rate-16 breaths per minute, FIO2-30%, and assist-control mode; weaned to T-piece at 40% and 8 liters of oxygen
Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0) Subjective/Objective cues: Objective cues: GCS 5 –best motor response is in decorticate position graded as 3 Unable to perform active range of motion exercises on all extremities Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities, no joint motion) Hand grasp of 0/3-none on both hands
Nursing Diagnosis with Etiology Impaired physical mobility related to limitation in independent purposeful physical movement of the body secondary to motor never compression on frontal lobe
Goals of Care Interventions General/Specific General: Independent: Within 2 weeks of Assessment: medical and nursing Assess for interventions, client will developing be able to maintain or thrombophlebitis increase strength of the (calf pain, body and extremities. Homan’s sign, redness, Specific: localized Within 1 week of medical swelling, and and nursing hyperthermia) interventions, client will be able to: Assess skin Improve muscle integrity strength on all extremities Perform passive exercises on all extremities
Rationale
Therapeutic Keep side rails up and bed in low position
Bed rest immobility promotes formation
Evaluation
or Patient displays no signs of calf pain, redness and on lower clot swelling extremities, or hyperthermia.
Regular examination of the skin especially on bony prominences will allow for prevention or early recognition and treatment of pressure sores.
Skin is dry, wrinkled, and rebounds instantly; with no signs of pressure sores or redness over bony prominences.
This promotes a safe environment
Patient is frequently monitored; secured raised side rails at all times; placed in low or semi-Fowler’s position
Turn patient every two hours
Maintain limbs in functional alignment
Perform passive ROM exercises on all extremities
Use pressurerelieving devices as indicated
Dependent: Administer medications as ordered such as antispasmodic drugs (e.g. Vitamin B complex)
Turning position optimizes circulation to all tissues and relieves pressure.
Patient is repositioned every 2 hours, massaged bony prominences, and placed pillows or rolled cloth for limbs and body support.
Maintaining proper alignment pf extremities prevents contractures.
Patient was provided with pillows and properly rolled cloth to maintain alignment and support on all limbs.
Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength. This prevents tissue breakdown
Passive range of motion exercises was provided to patient on all extremities with proper support and execution.
Antispasmodic medications may reduce muscle spasms that interfere with mobility.
Vitamin B complex (Polynerv) 500 mg was given to patient
Placement of pillows or rolled cloth to prevent pressure of skin contact to surface; gentle massage on bony prominences was provided
Collaborative: Set-up a bowel program (e.g. adequate fluid, foods high in bulk, physical activity, stool softeners, laxatives) as needed. Record bowel activity level.
Prolonged bed rest, lack of exercise, and physical inactivity contribute to constipation. A variety of interventions will promote normal eliminations.
IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient, adjusted at a rate of 21 drops per minute; nutrition given through osteorized tube feeding of 1, 800 kcal in 6 equal feedings plus 6 egg whites; patient was also ordered with Lactulose 30 cc; no bowel movement noted since last week
Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0) Subjective/Objective cues: Objective cues: presence of surgical wound stitched across the right part of the head about 12 inches, vertical; with dry, intact 2 x 3 inches dressing
Nursing Diagnosis with Etiology Risk for infection related to tissue destruction susceptible for invasion of pathogens.
Goals of Care Interventions General/Specific General: Independent: Within 2 weeks of Assessment: medical and nursing Observe for interventions, client will localized signs of be able to infection at prevent/reduce risk for surgical incision infection. wound. Note signs and Specific: symptoms of Within 1 week of m edical sepsis; fever,
Rationale
To check for any signs of infection
Evaluation
Signs of infection were not noted; no visible signs of redness or pus around surgical site.
To check for the With normal temperature presence of ranges from 35.6 C to infection and give 37. 1 C taken at left
on right parietal part of head
increased WBC (laboratory result of 14. 6 meq/L on January 7, 2013 ) Presence of an indwelling catheter and endotracheal tube
and nursing chills, interventions, client will diaphoresis. be able to manifest: Therapeutic: Absence of Change serosanguinous surgical/wound drainage from the dressings, as surgical site. indicated, using aseptic technique for changing/ Decrease or disposing of normal WBC contaminated value. materials. Health Teachings: Teach family how to clean incision site daily and remind them to change dressings as needed. Dependent: Administer or monitor medication regimen (e.g. antibiioticsLevofloxacin 750 mg, Vigocid 2.25 gm) and note patient’s response. Collaborative: Note and report laboratory values
necessary interventions.
axilla; chills and diaphoresis not noted
To facilitate wound healing and prevent infection by minimizing growth and spread of microorganisms.
Staff nurse on duty performed changing of surgical dressing, as indicated.
To educate the family about the right procedure to clean and change dressings.
Significant other was instructed to follow correct hand washing and aseptic technique whenever in contact with a surgical wound.
To determine Medications as directed effectiveness of follows the treatment duration for a certain therapy. number of days; completed the treatment regimen; temperature is within normal level of 35.6 C – 37 C;
To provide a global view of the patient’s immune function and nutritional status.
Latest lab values for WBC was not checked by student nurses
Subjective/Objective cues: Objective cues:
Nursing Diagnosis with Etiology Constipation related to inhibited defecation secondary to Unable to pass reflex of the stool since last compression week; with diet of pudendal nerve on the osteorized tube medial prefrontal lobe of feeding of 1, 800 the brain kcal in 6 equal feeding plus 6 egg whites Inactivity, GCS 5 –best motor response is in decorticate position graded as 3 muscle grade of 1/5 (muscle contraction on all extremities but no joint motion
Goals of Care General/Specific General: Within 3 weeks of medical and nursing interventions, client will be able to pass out soft, formed stool
Interventions Independent Assessment
Specific: Within 1 day of medical and nursing interventions, client will be able to:
Rationale
maintain normal bowel sounds within the range of 5-32 gurgling or clicking sounds perform passive ROM exercises on all extremities
assess usual pattern of elimination; compare with present pattern, include size, frequency, color, and quality
evaluate laxative use, type, and frequency
assess level
activity
evaluate current medication usage that may contribute to
normal frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is “normal” for each individual chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Over time, the colon becomes atonic and distended. Prolonged bed rest, lack of exercise, and inactivity causes constipation Drugs that can cause constipation include the
Evaluation
constipation
Therapeutic provide fluid intake of 2000 to 3000 mL/day, if not contraindicated medically
provide passive ROM exercises on all extremities
Health Teachings reinforce to caregiver the importance of the following:
a balanced diet consisting of
following: narcotics, antacids, antidepressants, anticholinergics, antihypertensive, general anesthetics, hypnotics, and iron and calcium supplements
Patients, especially older patients, may have cardiovascular limitations that require that less fluid be taken Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitates defecation These steps lead to reestablishing regular bowel habits Twenty grams of fiber per day is
adequate fiber, fresh fruits, vegetables and grains adequate fluid intake (20003000 mL/day) regular exercise and activity
regular meals
recommended
Increased hydration promotes softer fecal mass Exercise strengthen abdominal muscles and stimulate peristalsis Successful bowel training relies on routine
Dependent
administer drugs such as Lactulose, as ordered
Collaborative Health teachings teach use of medications as ordered, as in the following: bulk fiber (Metamucil)
This laxative is characterized by a shorter colon transit time and accelerated bowel movement.
This fluid,
increase gaseous,
stool softeners (Colace) chemical irritants (castor oil, cascara, milk of magnesia)
suppositories
oil retention enema
Subjective/Objective cues: Objective cues:
GCS of 6 (best eye openingopens to pain; verbal response1 with ET attached to VR; motor response3, flexes arms and extension of legs to pain)
Nursing Diagnosis with Etiology Risk for Aspiration related to decreased level of consciousness secondary to cerebral hypoperfusion
Goals of Care General/Specific General: Within 1 week of medical and nursing intervention, patient’s risk will decrease as a result of ongoing assessment and early interventions Specific: Within 1 day of medical
Interventions
and solid bulk of intestinal contents Softens stool and lubricates intestinal mucosa These irritate the bowel mucosa and cause rapid propulsion of contents and small intestine Softens stool and stimulates rectal mucosa Softens stool
Rationale
Evaluation
Subjective/Objective cues: Objective cues: GCS of 6 (best eye openingopens to pain; verbal response1 with ET attached to VR; motor response3, flexes arms and extension of legs to pain)
and nursing interventions, patient will be able to:
Absent cough reflex Presence of endotracheal, and nasogastric tubes attached to patient
Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities, no joint motion) Hand grasp of 0/3-none on both hands
Nursing Diagnosis with Etiology Self-Care Deficit related to decreased level of consciousness secondary to cerebral hypoperfusion and compression of the motor nerve on the frontal lobe
Maintain a patent airway
Goals of Care General/Specific General: Within 3 weeks of medical and nursing interventions, patient will be able to safely perform (to maximum ability) selfcare activities Specific: Within 1 day of medical and nursing interventions, patient will be able to:
Exhibit hygiene grooming
good and
Interventions
Rationale
Evaluation
