Nursing Care Plan

ASSESSMENT

SCIENTIFIC

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:

EXPLANATION
Impaired physical

Neuromuscular

Short term

Monitor V/S

To note changes

After 4 hours of

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

kamay at medyo

muscles. Voluntary

understanding

hindi ko rin maigalaw

muscles are the

situation or risk

diagnosis that

about the

ang kaliwa kong

ones that can be

factors and

contributes to

paa.

controlled, like in the

individual treatment

immobility

situations that may factors and

individual treatment
restrict

arms and legs. The

regimen and safety

nerve cells, also

measures

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

and collaborative

unhealthy or die,

nursing

Functional level:

communication

interventions,

level 2-requires help

between the nervous patient will

nursing intervention

comparison.

the patient was able

to verbalize

Determine the

To be informed

movements

understanding
situation or risk

regimen and safety

measures

Encourage and

the messages that

and for baseline

The longer the

facilitate early

patient remains

After 4 months of

ambulation and other

immobile the

continuous ,effective

Assist with each

greater the level of and collaborative

nursing
debilitation that

initial change:

will occur

ADLs when possible.

dangling, sitting in
chair, ambulation

interventions, patient
was able to maintain
position and function

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 weakness

extremities

stiffness, and

footdrop, decubitus

can lead to

maintains muscle

and so forth

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,

Massage back and

It provides comfort

an immune system

bony prominences

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

Assist in

Subjective:

Constipation related

A decrease in a

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

or return to normal

frequency and

causative and

establish or return to

defecation,

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

After 8 hours, the

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
Decrease gastric

thought to be one of
the reasons

Recommend

distress and

constipation is more

avoiding gas-

abdominal

common in older

forming foods

distention

people. Moreover,
increased physical
activity is more likely

Prevents skin

Assist in

to stimulate bowel

perianal skin

motility and improve

condition frequently,

the symptoms of

noting changes or

constipation.

beginning

excoriation and
breakdown

breakdown
Facilitates

Discuss use of

defecation when

stool softeners, mild

constipation is

stimulants, bulk-

present

forming laxatives, or
enemas as
indicated. Monitor

effectiveness
Constipation is a

Identify factors

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

RATIONALE

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

Vital signs

walang lasa

status requiring

consistent with a

nursing intervention,

monitored and

change in lifestyle

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

After 4 days of
For baseline
comparison

nursing interventions
the goal is met

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

blood pressure

will permit adaptation

factors like diet

hypertension

>fair appetite,

without adverse

to present medical

high in sodium,

selective with food

effects and without

situation

saturated fats and

>weak looking

EVALUATION

preferences

undue cost. To

cholesterol

achieve these goals,

BP-130/90 mmHg

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

the nurse must

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

patients BP

adequate rest
Emphasize the

Hypertension

importance of

needs medications

adherence to

to maintain the BP

medications

in its normal range

Provide an open

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
Generic Name:

Classification
Miscellaneous Fluids

Mannitol

or Diuretics

Brand Name:

Osmofudin 20%

Route and
Frequency:

IV q4
Dose:

100 cc

Side Effects
Dizziness

Contraindications
Hypersensitivity

increased

Headache

intracranial

Convulsions

Blurred vision

Diuresis

Dry mouth

Action

pressure

-increase osmotic

associated with

pressure of

cerebral edema

glomerular filtrate

Reduction of

Loss of hearing

Monitoring

Responsibilities
Assess patients

Parameters
Monitor vital

Severe renal

condition before

signs, CVP, and

disease

therapy and

urine specific

Severe

regularly

gravity

dehydration

thereafter to

Pulmonary

monitor drug

manifestations of

effectiveness

electrolyte

Assess for

imbalance

congestion

Monitor

which inhibits tubular

increased ocular

re-absorption of

pressure

possible drug

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.

water and

Indications
Reduction of

Nursing

failure

recognize and
immediately
report adverse

Assess BP before

reactions

Asses patients
and familys
knowledge of
drug therapy

Name of Drug
Generic Name:

Classification
CNS stimulants or

Citicholine

Neurotonics

Brand Name:

Indications
CVA in acute and

Action

involved in the

Route and
Frequency:

IV q12

Dose:

1 gm

to increased blood
flow and oxygen
consumption.

Hypersensitivity

parasympathetic

Signs and

Hypotension

nervous system

Insomnia

Stimulates

insufficiency.

biosynthesis of
lecithin. It is claimed

cerebral

Recent cranial
trauma

Contraindications
Hypertonia of the

recovery phase.
symptoms of

Cytidine Diphosphate -A derivative of

choline and cytidine
Choline

Side Effects
Shock

Parkinsons
disease

Nursing

Monitoring

Responsibilities
Evaluate patient

Parameters
Monitor vital signs

medical history

Pregnancy and
lactation

disturbances

Should not be

parasympathetic

discreet
effect

condition

hypertonia of the

fleeting and
hypotension

reaction like GI

patient with

action and

nervous system

Assess allergic

Assess patient

administered to

parasympathetic

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

Brand Name:

Altovast

Cardiovascular
Statins

Route and
Frequency:

Oral Od
Dose:

40 mg

Abdominal pain

cholesterol,

Constipation

to any component

fat , protein,

phophokinase

apolipoprotein

Flatulence

of the

carbohydrates;

levels due to

Insomnia

preparations

nutritional

possibility of

Headache

Children and

analysis should

myopathy; serum

Rashes

lactation

be completed by

cholesterol

dietitian before

Dizziness

Active liver

treatment is

triglycerides,

disease

Muscle cramps

Unexplained

initiated

cholesterol

Assess liver

baseline and

beta and

-Inhibits HMG-COA

triglycerides

which reduces

To increase HDL
cholesterol in the

cholesterol

treatment of

production

hyperlipidaemias

To reduce LDL

Action
reductase enzyme,

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

Monitoring

Responsibilities
Establish

Parameters
Monitor blood

Name of Drug
Generic Name:

Classification
Indications
Cardiovascular drugs Treatment of

Side Effects
Dry cough

Imidapril

antihypertensive

Headache

known

baselines in

Rash

hypersensitivity to

renal, liver

Palpitation

angiotensin

function tests

orthostatic

Fatigue

converting

before therapy

hypotension

Discomfort in the

Brand Name:

Vascor

Action
-inhibits angiotensin
converting enzyme;

Route and
Frequency:

Oral OD

reduction of
angiotensin II

Dose:

50 mg

throat

and reduction of
vascular resistance

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

hypertension

Contraindications
Patients with

Nursing

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

Action

HPN due to

-stimulates central-

Headache

phaeochromooyto

alpha adrenergic

ma

Fatigue

Anorexia

Anxiety

Brand Name:

Catapres

Route and
Frequency:

Oral OD

Indications
Management of

Dose:

75 mcg

receptors to inhibit

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

Monitor BP,
standing, sitting,

Perform blood

supine, mental

studies,

status, and heart

rate.

treatment of

cardioaccelareators

migraine or

neorophils,

and vasoconstrictor

recurrent

decreased

centers

vascular

platelets

and frequency

sympathetic

treatment of

Monitoring

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

SIDE EFFECTS

CONTRAINDICATIONS

NURSING

MONITORING

Generic Name:

Gastrointestinal /

Used in

Bradycardia

Hypersensitivity

RESPONSIBILITIES
Use caution in

PARAMETERS
Monitor AST,

Ranitidine

hepatobiliray Drugs

management of

Headache

History of acute

presence of renal

ALT, Serum

H2 Receptor

gastrointestinal

Fatigue

or hepatic

creatinine, signs

Antagonists

(GI) disorders.

Depression

impairment.

and symptoms of

Brand Name:
Zantac

Prophylaxis of

Mechanism of

GI hemorrhage

Action:

from stress

Rashes

porphyria
Long-term therapy

Assess for

peptic ulcer

potential for

disease, occult

interactions with

blood with GI

ulceration and in

other

bleeding.

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

Route:
I.V

Inhibits histamine

Constipation

Evaluate results of

Monitor renal

Dose:
50 mg

secretion.

anesthesia.

laboratory tests,
therapeutic
effectiveness.