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 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,  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, client will be able to Therapeutic manifest:  Position client in  Improve/Stable 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. 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

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)

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

g. and oculocephalic reflex-negative pressure.  Maintain airway patent  Prevents build up of secretions leading to increase in carbon dioxide and intracranial pressure.g. It maximizes cardiac output and prevents decreased cerebral perfusion associated with hypovolemia. With IV fluid of PNSS 1L x 63 cc per hour. Verapamil)  Diuretics are used and needed to decrease cerebral edema and anticonvulsant medications Mannitol 75 cc was given intravenously to patient. ET tube placement is monitored if securely attached to patient at the appropriate level of 21 cm. with a rate of 21 drops per minute  Restore maintain balance or fluid  . Mannitol) and anticonvulsants (e. Amlodipine. suctioned frequently for secretions Dependent:  Administer medications such as diuretics (e. to pain) Babinski reflexpositive. patent and infusing well at left metacarpal vein of patient. antihypertensives such Amlodipine 20 mg per tablet and Verapamil 10 mg per tablet was also given to patient Collaborative:  Review oximetry pulse  saturation Hypoxia is Oxygen associated with patient ranges 98-99% reduced cerebral tissue perfusion.

breath sounds. crackles. regular in rate and rhythm. Within 1 day of medical tachypnea. S/P craniotomy.g. right FTP area. and nursing stridor.  Assess client will be able to respiration and mobilize secretions.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.Patient’s Name/Bed #: Mr. verbal response1 with ET attached to VR. adventitious breath sounds heard over left anterior lung. suctioned frequently for presence of secretions. motor response3. and flexes late signs arms and extends legs to painful stimuli-3) Maintaining the airway is always first priority. client will wheezes) be able to manifest:  Clear breath  Evaluate sounds cough/gag reflex  Decreased and swallowing secretions ability  Assess airway for patency Rationale Evaluation   Respirations range between 16-21 breaths per minute. with ET tube attached-1. JP drain (0/0/0) Subjective/Objective cues: Subjective cues: None. Placement of ET tube on patient is monitored frequently at the appropriate level of 21 cm. Lethargy and Patient is GCS 5 (no eye somnolence are opening-1.   Assess changes in mental status  . evacuation of epidural and subdural hematoma. S/P repeat craniotomy. with absent own airway cough reflex These signs and symptoms are indicative of respiratory distress and/or accumulation of secretions. 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 medical Assessment and nursing intervention. A SICU0 Medical Diagnosis: epidural hematoma. noting rate and Specific sounds (e. especially in cases of trauma. evacuation of subdural hematoma. right FTP (0/0/0). interventions. tenacious secretions approximately 20 cc  Decreased level of consciousness (GCS of 6: best eye openingopens to pain. including ronchi and wheezing sounds exhibits To determine Patient swallowing and gag ability to protect reflexes.

 Patient is monitored frequently.  Use humidifier. monitored frequently from getting used up  Institute suctioning of the airway. of secretions . provided with chest physiotherapy upon change of position  Routinely check the patient’s position so he does not slide down in bed. This prevents abdominal contents from pushing upward and inhibiting lung expansion.  Patients VR set-up cmes with a humidifier. made comfortable in bed while adjusting pillows. approximately 20 cc Patient was repositioned every two hours. Note presence of sputum. with whitish.  Therapeutic  Elevate head of bed and reposition every 2 hours and as needed. odor and consistency.  is suctioned Helps clear Patient frequently for presence secretions. with slight elevation of the foot part to prevent sliding down the bed. color. This loosens secretions and facilitates the removal. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments.  Abnormalities maybe a result of infection. amount. tenacious secretions noted upon suctioning of the mouth and ET tube. A sign of infection is discolored sputum. assess quality.

regular. with no side effects such as hypotension or bradycardia. Collaborative  Check and monitor VR setup and patient’s response. back up rate-16 breaths per minute.  These promote clearance of airway secretions and bronchodilation decreases airway resistance.Dependent  Administer medications (e.  The basis for setting every parameter of the ventilator depends on the patient. With ET tube at 21 cm attached to patient connected to a functional ventilator. weaned to T-piece at 40% and 8 liters of oxygen . noting effectiveness and side effects. with respiratory rate of 17-21 breaths per minute. bronchodilatorsSalbutamol) as ordered. Vigocid. non-labored.g. mucolytic agents. and assist-control mode. antibioticsLevofloxacin. peak flow-50. Maintaining the correct settings for every parameter ensures the proper ventilation to the patient. Patient was given ILN Salbutamol 1 nebule via face mask. with VR set-up of: tidal volume-450 ml. FIO2-30%.

Skin is dry.Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma. client will developing be able to maintain or thrombophlebitis increase strength of the (calf pain. raised side rails at all times. redness and on lower clot swelling extremities.  Regular examination of the skin especially on bony prominences will allow for prevention or early recognition and treatment of pressure sores. body and extremities. Therapeutic  Keep side rails up and bed in low position  This promotes a Patient is frequently secured safe environment monitored. right FTP (0/0/0). Specific: localized Within 1 week of medical swelling. evacuation of subdural hematoma. redness. S/P craniotomy. and rebounds instantly. wrinkled. with no signs of pressure sores or redness over bony prominences. 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. and and nursing hyperthermia) interventions. right FTP area. S/P repeat craniotomy. evacuation of epidural and subdural hematoma. client will be able to:  Assess skin  Improve muscle integrity strength on all extremities  Perform passive exercises on all extremities Rationale Evaluation  Bed rest immobility promotes formation or Patient displays no signs of calf pain. 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. or hyperthermia. Homan’s sign. placed in low or semi-Fowler’s position .

gentle massage on bony prominences was provided Dependent:  Administer medications as ordered such as antispasmodic drugs (e. Patient is repositioned every 2 hours. prevents stiffness.g. Exercise promotes increased venous return. Vitamin B complex)  Vitamin B complex Antispasmodic (Polynerv) 500 mg was medications may reduce muscle given to patient spasms that interfere with mobility.  Maintain limbs in functional alignment  Maintaining proper alignment pf extremities prevents contractures. Passive range of motion exercises was provided to patient on all extremities with proper support and execution. and maintains muscle strength. and placed pillows or rolled cloth for limbs and body support. massaged bony prominences. . This prevents tissue breakdown  Perform passive ROM exercises on all extremities   Use pressurerelieving devices as indicated  Placement of pillows or rolled cloth to prevent pressure of skin contact to surface. Turn patient every two hours  Turning position optimizes circulation to all tissues and relieves pressure. Patient was provided with pillows and properly rolled cloth to maintain alignment and support on all limbs.

Goals of Care Interventions General/Specific General: Independent: Within 2 weeks of Assessment: medical and nursing  Observe for interventions. Record bowel activity level. right FTP area. nutrition given through osteorized tube feeding of 1. evacuation of subdural hematoma. stool softeners. intact 2 x 3 inches dressing Nursing Diagnosis with Etiology Risk for infection related to tissue destruction susceptible for invasion of pathogens. 800 kcal in 6 equal feedings plus 6 egg whites.  Prolonged bed rest. and physical inactivity contribute to constipation.6 C to infection and give 37. 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. S/P repeat craniotomy. with dry. 1 C taken at left  . Rationale Evaluation  To check for any Signs of infection were signs of infection not noted. patient was also ordered with Lactulose 30 cc. laxatives) as needed. fever. To check for the With normal temperature presence of ranges from 35. S/P craniotomy. patent and infusing well at left metacarpal vein of patient. physical activity.Collaborative:  Set-up a bowel program (e.g. wound. evacuation of epidural and subdural hematoma. A SICU0 Medical Diagnosis: epidural hematoma. client will localized signs of be able to infection at prevent/reduce risk for surgical incision infection. no bowel movement noted since last week Patient’s Name/Bed #: Mr. right FTP (0/0/0).  Note signs and Specific: symptoms of Within 1 week of medical sepsis. IV fluid of PNSS 1L x 63 cc per hour. adequate fluid. no visible signs of redness or pus around surgical site. A variety of interventions will promote normal eliminations. adjusted at a rate of 21 drops per minute. foods high in bulk. lack of exercise. vertical.

g. Health Teachings:  Teach family how to clean incision site daily and remind them to change dressings as needed. . materials. using aseptic technique for changing/  Decrease or disposing of normal WBC contaminated value.  To provide a Latest lab values for global view of the WBC was not checked patient’s immune by student nurses function and nutritional status. Vigocid 2. client will diaphoresis.on right parietal part of head  increased WBC (laboratory result of 14.25 gm) and note patient’s response. 2013 ) Presence of an indwelling catheter and endotracheal tube  and nursing chills. be able to manifest: Therapeutic:  Absence of  Change serosanguinous surgical/wound drainage from the dressings. Dependent:  Administer or monitor medication regimen (e. temperature is within normal level of 35. indicated.  To educate the family about the right procedure to clean and change dressings.  To determine Medications as directed effectiveness of follows the treatment duration for a certain therapy. as surgical site. axilla. as indicated. number of days. 6 meq/L on January 7.  To facilitate wound healing and prevent infection by minimizing growth and spread of microorganisms. interventions. Significant other was instructed to follow correct hand washing and aseptic technique whenever in contact with a surgical wound. completed the treatment regimen.6 C – 37 C. antibiioticsLevofloxacin 750 mg. Collaborative:  Note and report laboratory values necessary interventions. chills and diaphoresis not noted Staff nurse on duty performed changing of surgical dressing.

compare with present pattern. and quality  Rationale Evaluation   evaluate laxative use. the colon becomes atonic and distended. 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 Nursing Diagnosis with Etiology Constipation related to inhibited defecation reflex secondary to compression of the pudendal nerve on the medial prefrontal lobe of the brain Goals of Care General/Specific General: Within 3 weeks of medical and nursing interventions. 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. color. 800 kcal in 6 equal feeding plus 6 egg whites Inactivity. Prolonged bed rest. and inactivity causes constipation Drugs that can cause constipation include the . formed stool Specific: Within 1 day of medical and nursing interventions. frequency. Over time. client will be able to pass out soft. 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. lack of exercise. type. include size. client will be able to:  maintain normal bowel sounds within the range of 5-32 gurgling or clicking sounds perform passive ROM exercises on all extremities Interventions Independent Assessment  assess usual pattern of elimination. with diet of osteorized tube feeding of 1.Subjective/Objective cues: Objective cues:  Unable to pass stool since last week.

general anesthetics. antihypertensive. hypnotics. antidepressants. antacids. especially older patients. 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   . anticholinergics. 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 Therapeutic  provide fluid intake of 2000 to 3000 mL/day.constipation following: narcotics. and iron and calcium supplements  Patients.

adequate fiber. as ordered  This laxative is characterized by a shorter colon transit time and accelerated bowel movement. as in the following: bulk fiber (Metamucil)  This fluid. . Collaborative Health teachings  teach use of medications as ordered. fresh fruits. vegetables and grains adequate fluid intake (20003000 mL/day) regular exercise and activity  recommended  regular meals  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. increase gaseous.

hypoperfusion verbal response1 with ET attached to VR. motor response3.secondary to cerebral opens to pain. patient’s risk will decrease as a result of ongoing assessment and early interventions Specific: Within 1 day of medical Interventions Rationale Evaluation . cascara. flexes arms and extension of legs to pain) Goals of Care General/Specific General: Within 1 week of medical and nursing intervention.stool softeners (Colace) chemical irritants (castor oil. milk of magnesia)   suppositories   oil retention enema 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 Subjective/Objective cues: Objective cues:  Nursing Diagnosis with Etiology Risk for Aspiration related to decreased GCS of 6 (best level of consciousness eye opening.

and nasogastric tubes attached to patient and nursing interventions. flexes arms and extension of legs to pain)  Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities. patient will be able to:  Exhibit hygiene grooming good and Interventions Rationale Evaluation  . motor response3. verbal response1 with ET attached to VR. patient will be able to safely perform (to maximum ability) selfcare activities Specific: Within 1 day of medical and nursing interventions. 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 Goals of Care General/Specific General: Within 3 weeks of medical and nursing interventions. patient will be able to:  Maintain a patent airway Subjective/Objective cues: Objective cues:  GCS of 6 (best eye openingopens to pain.  Absent cough reflex Presence of endotracheal.

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