Rhea Mae V.

Valles
BSN-III
Pt. N.A. 1y/o

Assessment
Subjective:
Naninigas ang
kanyang braso at
paa mga ilang
segundo as
verbalized by
patient.
Objectives:
limited
range of
motion
(patient is
on a
decorticate
position)
c pupillary
size of
3mm on
right eye,
2mm on
left eye,
both eyes
with
negative

Diagnosis

Planning

Impaired
physical
mobility related
to
neuromuscular
damage

After 12 hours of
nursing interventions,
client will be able to
manifest:
Improve/Stable
level of
consciousness
Improve/Stable
GCS score
No pupillary
changes,
seizures,
widening of
pulse pressure,
irregular
respirations,
hypotension
and bradycardia

Interventions
Nsg. Action
Rationale
Independent:
Assessment
1. Assess mental
status and
changes in the
level of
consciousness
.
Therapeutic
2. Position client
in lowfowlers
position
(30degrees).
3. Avoid
extreme
rotation of the
neck.
4. Avoid
extreme hip
flexion.
5. Maintain
patent airway.
Dependent

Evaluation

After 12 hours of
nursing
interventions, client
was able to
1. To check for
affected cranial manifest:
Improve/Sta
nerve functions
ble level of
in the brain
consciousne
(for GCS);
ss
check for
Improve/Sta
cerebral hypo
perfusion and
ble GCS
hypoxia.
score
2. Help venous
No pupillary
drainage from
changes,
the brain and
seizures,
promote brain
widening of
expansion.
pulse
3. This will
pressure,
compress the
irregular
jugular veins
respirations,
leading to an
hypotension
increased
and
intracranial
bradycardia
pressure.
4. Increase in

reaction to
light
Muscle
grade of 1/5
for slight
muscle
contraction
on all
extremities,
no joint
motion
With GCS
of 6(best
eye
openingopens to
pain; verbal
response-1
with ET
attached to
VR; motor
response3,flexes
arms and
extension
of legs to
pain)
weak in
appearance
warm to
touch

6. Administer
medications
such as
diuretics (e.g.
Mannitol) and
anticonvulsan
ts(e.g.
Amlodipine,
Verapamil)
Collaborative
7. Review pulse
oximetry.
8. Restore or
maintain fluid
balance.

5.

6.

7.

8.

intraabdominal and
intra-thoracic
pressure
leading to
increased
intracranial
pressure.
Prevents
buildup of
secretions
leading to
increase in
carbon dioxide
and
intracranial
pressure.
Diuretics are
used and
needed to
decrease
cerebral edema
and
anticonvulsant
medications.
Hypoxia is
associated with
reduced
cerebral tissue
perfusion.
It maximizes

V/S taken
as follow:
T: 37.1
P: 120
R: 32
BP: 80/50

cardiac output
and prevents
decreased
cerebral
perfusion
associated with
hypovolemia.