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 clients normal range, alert/oriented, balanced intake/output, absence of edema, free of pain/discomfort). Interventions Evaluation Promotive: 1. Assessed the patients 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/

examinations.) Rationale: to determine location/severity of condition. -

- 1300H:72bpm/ 37.1C/120/80mmHg/20cpm - 1400H:68bpm/ 37.2C/110/70mmHg/20cpm CT Scan of the brain (Feb.16,11) showed that there is no evidence of an acute intracranial hemorrhage, pneumocephalus along the left frontal convexity. - ECG(Feb.2,11) Mild Mitral Regurgitation - Ultrasound of the neck with color Doppler (Feb.10,11) showed that there has complex mass in right thyroid lobe with 10cm x 6cm x 4cm firm, non-movable mass. - CBC(Feb.23,11) high WBC 11.27x10^3/uL (4.4-11); high Segmenters 86% (40-70); low Lymphocytes 10% (22-43);low Osmolality 270mOsm/kg H2 (275-295); high cholesterol 243.56 mg/dL (<200); high HDL cholesterol 63.45 mg/dL (40-60); high ALDL 157.08 mg/dL (0-100); High alkaline phosphate 112 u/L (35-105); high fasting blood sugar 149.79 mg/dL (70110) Numbness in the right face including right side of the neck, right arm, and right side of the trunk and right side extremities. According to the husband, Lagi na lang siyang nagagalit kahit walang dahilan. Lagi nalang galit at iritable. Patient had 1 episode of blackout PTA admission.

4. Determined presence of visual, sensory/motor changes, headache, dizziness, altered mental status, personality changes. 5. Noted history of syncope, brief/intermittent periods of confusion/blackout. Rationale: Suggestive of a transient ischemic attack (TIA). 6. Assisted with treatment of underlying conditions (e.g., surgical reperfusion procedures, medications, fluid replacement/rehydration, nutrients, treatment of sepsis, etc.), as indicated.

Rationale: to improve tissue perfusion/organ function. 7. Encouraged use of relaxation activities, exercises/techniques. 8. Established/ encouraged regular exercise program. Rationale: to decrease tension level 9. Measured intake and output accurately. Rationale: to determine if there is possible occurrence of fluid overload. Preventive: 10. Reviewed specific dietary changes/restrictions with client (e.g., reduction of cholesterol and triglycerides, high or low protein intake). 11. Identified necessary changes in lifestyle and assisted client to incorporate disease management into ADLs. 12. Elevated HOB (e.g., 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. Low fat, low salt with Diabetic Specified plus 1 banana per meal. Intake of 890 mL and Output of 6 urine and no stool. Patient has a regular schedule with physical therapy every AM. Patient was seen listening to music. 1) PNSS1L x 10hours 25 gtts/min 2) PLRS1L x 10hours 25 gtts/min

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

Patient was able to tolerate the medications given.

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

5. Noted emotional/behavioral responses to problems of immobility. Feelings of frustration/powerlessness may impede attainment of goals. 6. Supported affected body parts/joints using

Patient was seen determined to move her affected leg.

pillows/rolls, foot supports/shoes, air mattress, water bed, and so forth. Rationale: to maintain position of function and reduce risk of pressure ulcers. 7. Scheduled activities with adequate rest periods during the day. Rationale: to reduce fatigue. 8. Encouraged participation in self-care, occupational/diversional/recreational activities. Rationale: Enhances self-concept and sense of independence. 9. Encouraged adequate intake of fluids/nutritious foods. Rationale: Promotes well-being and maximizes energy production. 10. Instructed to perform passive ROM in the -

One pillow was placed under the affected leg.

Patient was able to rest and there was no discomforts noted.

Patient reported that she was able to do passive ROM to the affected side alone.

Showed compliance to the diet prescribed. (Low fat, low salt with Diabetic Specified plus 1 banana per meal)

During the last day that the patient was handled by the student nurses, the affected

affected area.

leg was able to move from side to side, up and down. She was able to dangled her foot without difficulties. The patient used the side rails, which was kept up, to turn from sides.

Preventive: 1. Instructed in use of side rails, overhead trapeze, roller pads. Rationale: for position changes/transfers.

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

coherent and oriented to time, place and person.

excision under image guidance.

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