NURSING CARE PLAN Name of Patient: X Medical Diagnosis: Chronic renal failure secondary to DM nephropathy.

Nursing Diagnosis: Risk for ineffective protection related to abnormal blood profile. Findings O= Received patient on bed, awake, conscious with intravenous fluid of # 1 D5 0.3% NaCl 500cc @ KVO, infusing well at left arm. > With ventriculostomy tube freely draining to blood bag; dressing is dry and intact. > With traeostomy attached to mechanical ventilator, with FIO2 of 80%. > With nasogastric tube for feeding. WBC= 20T RBC= 3.5 million/uL > With the following vital signs of: >T=36.5oC. >P=100bpm. >R= 22 cpm. >BP=130/80mmhg Noted By: Senior/ Staff Nurse & Nurse Supervisor Expected Outcome Within 8 hours of nursing intervention, the patient will be able to: 1. Experience no signs/ symptoms of bleeding. 2. Maintain / demonstrate improvement in laboratory values. Nursing Interventions and Rationale -Hand washing and observe proper medical asepsis and limit visitors. R= to limit transmission of infections since the patient has a weak immune system. -Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient activities to avoid fatigue. R=May reflect effects of anemia and cardiac response. To let the patient rest. -Note for the sign of infections in the operative site and change the dressing regularly. R= since the patient undergone ventriculostomy, noting and changing the dressing can help minimize the infection. Actual Evaluation After 7-8 hours of nursing intervention, the patient was: 1. Still in coma, no signs of increased ICP noted. 2. Displayed no further deterioration. 3. With stable vital signs of >T=36.8oC. >P= 101 bpm. >R= 21 cpm. >BP=140/80mmhg

NURSING CARE PLAN Name of Patient: X Medical Diagnosis: Acute Myocardial Infarction

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility Findings O= Received patient on bed, awake, conscious with intravenous fluid of # 1 D5 0.3% NaCl 500cc @ KVO, infusing well at left arm. > With ventriculostomy tube freely draining to blood bag; dressing is dry and intact. > With traeostomy attached to mechanical ventilator, with FIO2 of 80%. > With nasogastric tube for feeding. WBC= 20T RBC= 3.5 million/uL > With the following vital signs of: >T=36.5oC. >P=100bpm. >R= 22 cpm. >BP=130/80mmhg Noted By: Senior/ Staff Nurse & Nurse Supervisor Expected Outcome Within 8 hours of nursing intervention, the patient will be able to: 1. Experience no signs/ symptoms of bleeding. 2. Maintain / demonstrate improvement in laboratory values. Nursing Interventions and Rationale -Hand washing and observe proper medical asepsis and limit visitors. R= to limit transmission of infections since the patient has a weak immune system. -Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient activities to avoid fatigue. R=May reflect effects of anemia and cardiac response. To let the patient rest. -Note for the sign of infections in the operative site and change the dressing regularly. R= since the patient undergone ventriculostomy, noting and changing the dressing can help minimize the infection. Actual Evaluation After 7-8 hours of nursing intervention, the patient was: 1. Still in coma, no signs of increased ICP noted. 2. Displayed no further deterioration. 3. With stable vital signs of >T=36.8oC. >P= 101 bpm. >R= 21 cpm. >BP=140/80mmhg

NURSING CARE PLAN Name of Patient: X Medical Diagnosis:

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility Findings O= Received patient on bed, awake, conscious with intravenous fluid of # 1 D5 0.3% NaCl 500cc @ KVO, infusing well at left arm. > With ventriculostomy tube freely draining to blood bag; dressing is dry and intact. > With traeostomy attached to mechanical ventilator, with FIO2 of 80%. > With nasogastric tube for feeding. WBC= 20T RBC= 3.5 million/uL > With the following vital signs of: >T=36.5oC. >P=100bpm. >R= 22 cpm. >BP=130/80mmhg Noted By: Senior/ Staff Nurse & Nurse Supervisor Expected Outcome Within 8 hours of nursing intervention, the patient will be able to: 1. Experience no signs/ symptoms of bleeding. 2. Maintain / demonstrate improvement in laboratory values. Nursing Interventions and Rationale -Hand washing and observe proper medical asepsis and limit visitors. R= to limit transmission of infections since the patient has a weak immune system. -Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient activities to avoid fatigue. R=May reflect effects of anemia and cardiac response. To let the patient rest. -Note for the sign of infections in the operative site and change the dressing regularly. R= since the patient undergone ventriculostomy, noting and changing the dressing can help minimize the infection. Actual Evaluation After 7-8 hours of nursing intervention, the patient was: 1. Still in coma, no signs of increased ICP noted. 2. Displayed no further deterioration. 3. With stable vital signs of >T=36.8oC. >P= 101 bpm. >R= 21 cpm. >BP=140/80mmhg

NURSING CARE PLAN Name of Patient: X Medical Diagnosis:

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility Findings O= Received patient on bed, awake, conscious with intravenous fluid of # 1 D5 0.3% NaCl 500cc @ KVO, infusing well at left arm. > With ventriculostomy tube freely draining to blood bag; dressing is dry and intact. > With traeostomy attached to mechanical ventilator, with FIO2 of 80%. > With nasogastric tube for feeding. WBC= 20T RBC= 3.5 million/uL > With the following vital signs of: >T=36.5oC. >P=100bpm. >R= 22 cpm. >BP=130/80mmhg Noted By: Senior/ Staff Nurse & Nurse Supervisor Expected Outcome Within 8 hours of nursing intervention, the patient will be able to: 1. Experience no signs/ symptoms of bleeding. 2. Maintain / demonstrate improvement in laboratory values. Nursing Interventions and Rationale -Hand washing and observe proper medical asepsis and limit visitors. R= to limit transmission of infections since the patient has a weak immune system. -Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient activities to avoid fatigue. R=May reflect effects of anemia and cardiac response. To let the patient rest. -Note for the sign of infections in the operative site and change the dressing regularly. R= since the patient undergone ventriculostomy, noting and changing the dressing can help minimize the infection. Actual Evaluation After 7-8 hours of nursing intervention, the patient was: 1. Still in coma, no signs of increased ICP noted. 2. Displayed no further deterioration. 3. With stable vital signs of >T=36.8oC. >P= 101 bpm. >R= 21 cpm. >BP=140/80mmhg

NURSING CARE PLAN Name of Patient: X Medical Diagnosis:

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility Findings O= Received patient on bed, awake, conscious with intravenous fluid of # 1 D5 0.3% NaCl 500cc @ KVO, infusing well at left arm. > With ventriculostomy tube freely draining to blood bag; dressing is dry and intact. > With traeostomy attached to mechanical ventilator, with FIO2 of 80%. > With nasogastric tube for feeding. WBC= 20T RBC= 3.5 million/uL > With the following vital signs of: >T=36.5oC. >P=100bpm. >R= 22 cpm. >BP=130/80mmhg Noted By: Senior/ Staff Nurse & Nurse Supervisor Expected Outcome Within 8 hours of nursing intervention, the patient will be able to: 1. Experience no signs/ symptoms of bleeding. 2. Maintain / demonstrate improvement in laboratory values. Nursing Interventions and Rationale -Hand washing and observe proper medical asepsis and limit visitors. R= to limit transmission of infections since the patient has a weak immune system. -Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient activities to avoid fatigue. R=May reflect effects of anemia and cardiac response. To let the patient rest. -Note for the sign of infections in the operative site and change the dressing regularly. R= since the patient undergone ventriculostomy, noting and changing the dressing can help minimize the infection. Actual Evaluation After 7-8 hours of nursing intervention, the patient was: 1. Still in coma, no signs of increased ICP noted. 2. Displayed no further deterioration. 3. With stable vital signs of >T=36.8oC. >P= 101 bpm. >R= 21 cpm. >BP=140/80mmhg

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