NURSING CARE PLAN Nursing Diagnosis # 1: Ineffective cerebral Tissue Perfusion related to interruption of arterial blood flow as evidenced

by presence of mass in the left parietal lobe, numbness of the right face including right side of the neck, right arm, and right side of the trunk and right side extremities. Goal: To increase and maintain normal level of oxygen. Expected Outcome: At the end of 8 hours nursing intervention, the client will be able to: 1. Verbalize understanding of condition, therapy regimen, side effects of medications, and when to contact healthcare provider. 2. Demonstrate behaviors/lifestyle changes to improve circulation (e.g., cessation of smoking, relaxation techniques, exercise/dietary program). 3. Demonstrate increased perfusion as individually appropriate (e.g., skin warm/dry, peripheral pulses present/strong, vital signs within client’s normal range, alert/oriented, balanced intake/output, absence of edema, free of pain/discomfort). Interventions Evaluation Promotive: 1. Assessed the patient’s health condition. Rationale: to provide baseline data. 2. Monitored vital signs especially blood pressure, heart rate, respiratory rate and temperature every hour. Rationale: to note if there are any relevant changes. 3. Reviewed results of diagnostic studies (e.g., ultrasound/ CT/other imaging scans, CBC, Crea Profile, and other laboratory - Patient was seen awake, conscious,

coherent and oriented to time, place and person. - 0700H:60bpm/37.2C/ ̊ 130/90mmHg/19cpm - 0800H:72bpm/ 37.2C/ ̊ 20cpm - 0900H:68bpm/ 36.8C/ ̊ 20cpm - 1000H:70bpm/ 120/80mmHg/18cpm - 1100H:64bpm/ 110/80mmHg/20cpm - 1200H:66bpm/ 120/80mmHg/19cpm

130/80mmHg/ 110/70mmHg/ 36.6C/ ̊ 37.0C/ ̊ 37.0C/ ̊

2. non-movable mass. etc. high fasting blood sugar 149. personality changes..1C/120/80mmHg/20cpm ̊ . According to the husband.08 mg/dL (0-100).CBC(Feb. Determined presence of visual. as indicated. high Segmenters 86% (40-70). 6.79 mg/dL (70110) Numbness in the right face including right side of the neck. 4.” Patient had 1 episode of blackout PTA admission.23. headache.10. - . right arm. pneumocephalus along the left frontal convexity.). surgical reperfusion procedures.’11) high WBC 11. - . . sensory/motor changes. altered mental status.) Rationale: to determine location/severity of condition. .27x10^3/uL (4. treatment of sepsis.’11) showed that there is no evidence of an acute intracranial hemorrhage.56 mg/dL (<200). low Lymphocytes 10% (22-43). high HDL cholesterol 63.g. Noted history of syncope.16. medications. dizziness. brief/intermittent periods of confusion/blackout.Ultrasound of the neck with color Doppler (Feb. Lagi nalang galit at iritable. 5. High alkaline phosphate 112 u/L (35-105).2C/110/70mmHg/20cpm ̊ CT Scan of the brain (Feb.4-11).ECG(Feb. nutrients.’11) Mild Mitral Regurgitation .1400H:68bpm/ 37. and right side of the trunk and right side extremities. high cholesterol 243. high ALDL 157.45 mg/dL (40-60).low Osmolality 270mOsm/kg H2 (275-295).’11) showed that there has complex mass in right thyroid lobe with 10cm x 6cm x 4cm firm. fluid replacement/rehydration. “Lagi na lang siyang nagagalit kahit walang dahilan.1300H:72bpm/ 37. Rationale: Suggestive of a transient ischemic attack (TIA). Assisted with treatment of underlying conditions (e.examinations.

7. Elevated HOB (e.. Rationale: to decrease tension level 9. Intake of 890 mL and Output of 6 urine and no stool. 8. exercises/techniques. Measured intake and output accurately.. Patient has a regular schedule with physical therapy every AM. Patient was seen listening to music. high or low protein intake). Established/ encouraged regular exercise program. 12. 11. low salt with Diabetic Specified plus 1 banana per meal. 1) PNSS1L x 10hours 25 gtts/min 2) PLRS1L x 10hours 25 gtts/min .g. reduction of cholesterol and triglycerides. 30 degrees) and maintain head/neck in midline or neutral position Rationale: to promote circulation/venous drainage and to decrease blood flow for Patient verbalized understanding that she needs assistance when walking or transferring from one place to another.g. Identified necessary changes in lifestyle and assisted client to incorporate disease management into ADLs. Low fat. Reviewed specific dietary changes/restrictions with client (e. Preventive: 10.Rationale: to improve tissue perfusion/organ function. Encouraged use of relaxation activities. Rationale: to determine if there is possible occurrence of fluid overload.

. Assisted in administer medications (e.g. steroids/diuretics [may be used to decrease edema]. Curative: 13. anticoagulants). antihypertensive agents.possible increase intracranial pressure. - Patient was able to tolerate the medications given.. Maintained on HOB 30̊ until 1400H.

listening to client’s description. Interventions Evaluation Promotive: 1. Maintain or increase strength and function of affected and/or compensatory body part. Noted decreased motor agility/essential tremor related to age. the patient was able to recalled 3/3 words given. Patient cannot move her right leg and cannot dangle her right foot. 3. Verbalize understanding of situation and individual treatment regimen and safety measures. the client will be able to: 1. 4. Goal: To strengthen the affected area. . No pain was reported. Assessed nutritional status and client’s report of energy level. ( right leg ) Expected Outcome: At the end of 8 hours nursing intervention. oriented to three spheres and was able to follow different directions given. 3. 2. Assessed degree of pain.NURSING CARE PLAN Nursing Diagnosis # 2: Impaired physical Mobility may be related to neuromuscular involvement as evidenced by numbness of the right leg. Determined degree of perceptual/cognitive impairment and ability to follow directions. Demonstrate techniques/behaviors that enable resumption of activities. The patient has a good appetite and can consume all the food served. 2.

Scheduled activities with adequate rest periods during the day. low salt with Diabetic Specified plus 1 banana per meal) During the last day that the patient was handled by the student nurses. occupational/diversional/recreational activities. 10. Feelings of frustration/powerlessness may impede attainment of goals. Patient was able to rest and there was no discomforts noted. 6. 9.5. Instructed to perform passive ROM in the - One pillow was placed under the affected leg. Rationale: to reduce fatigue. the affected . Supported affected body parts/joints using - Patient was seen determined to move her affected leg. water bed. Rationale: Enhances self-concept and sense of independence. foot supports/shoes. air mattress. Rationale: Promotes well-being and maximizes energy production. 7. Noted emotional/behavioral responses to problems of immobility. Patient reported that she was able to do passive ROM to the affected side alone. and so forth. 8. Rationale: to maintain position of function and reduce risk of pressure ulcers. (Low fat. Encouraged adequate intake of fluids/nutritious foods. pillows/rolls. Encouraged participation in self-care. Showed compliance to the diet prescribed.

She was able to dangled her foot without difficulties. leg was able to move from side to side. up and down. Preventive: 1. The patient used the side rails. overhead trapeze. Instructed in use of side rails. to turn from sides. . Rationale: for position changes/transfers. which was kept up.affected area. roller pads.

3. coherent and oriented to time. such as chronic or debilitating conditions. 2. Assess muscle strength. . Review history of past or current physical injuries (e.g. Modify environment as indicated to enhance safety. Interventions Promotive: 1. gross and fine motor coordination. the client will be able to: 1. excision under image guidance. recent trauma. except for the lower leg 3/5. Observe individual’s general health status. Verbalize understanding of individual risk factors that contribute to possibility of falls. Be free of injury. gait. lifestyle changes to reduce risk factors and protect self from injury. 3.Patient Evaluation was seen awake. conscious. Rationale: noticing factors that might affect safety. use of multiple medications. Goal: To prevent falls. 2. orthopedic surgery) altering coordination. place and person.. and balance. Demonstrate behaviours. All other muscle areas are 5/5. Expected Outcome: At the end of 8 hours nursing intervention. 4. S/P Left parietal craniotomy tumor . musculoskeletal injuries.NURSING CARE PLAN Nursing Diagnosis # 3: Risk for Fall related to decrease muscle strength in the lower extremity (right leg).

Evaluate use/misuse/failure to use assistive aids. or might refuse to use devices for various reasons (e. when indicated. Patient was trying to stand from the wheelchair to transfer to bed alone. but is at high risk for falls while adjusting to altered body state and use of unfamiliar device. Kept side rails up. Instructed patient to call for assistance if needed. . No fall noted.4. waiting for help. No history of fall. prolonged bedrest. weakness. perception of weakness) 6. Patient verbalized understanding about the importance of having an assistance when moving. Rationale: unsafe environment to predict current risk for falls. 5. Rationale: Client may have assistive device. 7. sedentary lifestyle (changes in body due to disuse).g. Review history of prior falls associated with immobility..

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