University of San Carlos

School of Health Care Professions

Department of Nursing

NURSING CARE PLAN

Name of Patient: J.M
Age: 50 years old
Occupation: Government Employee
Date of Admission: July 15,2016
Status: Married

Health Profile: Received patient lying on bed awake with 1L PNSS @100 cc per hour,

Religion: Roman Catholic

Initial Complaint: Body Malaise, fever and lost of conciousness

Diagnosis/ Impression: 1 Sudural hematoma L frontotemporal convexities.

Needs/ NsgDx
Cues

Scientific Analysis

Ineffectiv
e cerebral
tissue
perfusion
related
to
interrupti
on of
blood
flow
secondary
to motor
vehicular
accident
as
manifeste
d by
altered
level of

If the increase of
pressure is high
enough, it can
cause
displacement of
the brain through
or against the
rigid structures of
the skull. This
causes restriction
of blood flow to
the brain
decreasing
oxygen delivery
and waste
removal.

( Brunner and
Suddarth's medical
surgical nursing p.2234)

Objectives

After 8 hours of nursing

interventions the
patient will :

Demonstrate
stable Vital signs
and absence of
signs of ICP as
evidence by
gradual
improvement of
vital signs
Maintain usual or
improved LOC ,
cognition and
motor and
sensory functions.

Nursing
Interventions

Monitor Vital
signs

Continual monitor
in changes in
orientation, ability
to speak, mood,
affect, visual and
sensory

Rationale

Serve as a
baseline data and
to monitor
condition of the
patient

Changes in
cognition and
speech content
are an indicator
for the degree
and location of
cerebral
involvement and
may indicate
increased ICP.

Reduces arterial
pressure by
promoting venous
drainage and may

Position with head

elevated and in
neutral position.

Evaluation

conscious
ness

Encourage quiet
and restful
environment

Demonstrate and
encourage use of
relaxation
techniques.

Prevent straining
of stool and
holding breath

SUBJECTI
VE
Sakit jud
kaayo akong
ulo, akong
pikas tiil day
oe
Katong lalaki
day ba wala
batsan, basa
man gud to,
Kinsa gani
pangan sa
akong Anak
day, naka limot
naman ko oy
as verbalized
by patient
Objectives:

VS taken
as follows :
BP: 110/70
PR : 70
RR :24
(increase
of RR is an
indicator
that
patient is
Tachypnic
)
Patient
appears
weak and

improve cerebral
circulation and
perfusion.

Conserve energy and

lower tissue O2
demands.

To decrease tension level

Valsalva's manuever
increase ICP and risk
for bleeding

lethargic
Restlessne
ss

Altered
level of
consciousn
ess (LOC) :
memory
loss
Generalize
d pain (10
as the
highest)
Pain scale of
7/10