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Problem #4: Confusion Date: April 6, 2018 at 8:00 AM

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Objective: Altered mental Independent: Goal partially
- Confusion status After 4 hours of - Monitor vital signs - To obtain baseline data and for met.
- Incomprehensibl secondary to nursing especially oxygen proper monitoring After 4 hours
e words when intervention, the saturation
transient of nursing
patient will be able
spoken to ischemic attack intervention,
to regain usual - Assess patient’s level of - To provide baseline for
- Disoriented to related to the patient was
reality, orientation consciousness and comparison with ongoing
time, place and inadequate and level of changes in behavior assessment findings able regain
person. cerebral oxygen consciousness. level of
- Vital signs: - Test ability to receive, - To assess degree of impairment
as evidenced by consciousness
 BP- send, and appropriately
confusion, but recurrent
110/80mmHg interpret communications
 PR-97bpm incomprehensibl confusion is
 RR-20bpm e words and - Perform periodic - Early recognition of changes still evident.
 T-36.4 disorientation. neurologic assessment, promotes proactive modifications
 O2 Sat.- 99% as indicated to plan of care

- Reorient to time, place, - Inability to maintain orientation is


and person as needed a sign of deterioration.

- Provide safety measures - To prevent further deterioration


such as side rails up, as and promote safety.
indicated.

- Maintain a pleasant, quiet - Provides stimulation while


environment and reducing fatigue.
approach client in a slow,
calm manner
Chapter IX

EVALUATION

Patient J.M.B. was one of the patients and became the focus of the

student’s case study during their 7-3 Shift at Ilocos Training and Regional

Medical Center, Medical Ward. He was admitted last April 6, 2018 with an

admitting diagnosis of Cerebrovascular Disease, Infarct Left Middle Cerebral

Artery. An interview and assessment were conducted to gather data and

information needed to create a nursing care plan that addressed the patient’s

problems and needs.

The patient was placed to room of choice and was hooked with an

ongoing intravenous line of PNNS 1L at KVO rate. Since verbal communication

between the nurses and the patient was impaired, they provided appropriate

health teachings to the family members instead; regarding proper nutrition,

proper hygiene, and important precautions of the associated risks of the patient.

Therefore, the patient’s family was able to gain knowledge and understanding

regarding the patient’s condition. Importance of having adequate nutrition and

healthy lifestyle was emphasized such as controlling high blood pressure, eating

healthy, seizing cigarette smoking, being physically active, losing weight,

controlling blood sure and managing cholesterol.

Patient-centered objectives were partially met despite the limited time

frame of our exposure and nurse-patient interaction. Throughout his confinement,

the patient was able to receive effective and efficient nursing interventions.

Regarding impaired verbal communication, the patient utilized the use of

gestures as an alternative form of communication to express his needs. For the

edema, the patient demonstrated signs of fluid balance such as semi-dry skin but

edematous extremities are still evident. For the activity intolerance, the patient

was able to participate willingly on desired activities such as performing self-care

activities but physiologic signs of introlerance are still evident. For the difficulty of
speaking, alternative forms of communication were used such as gestures by

simply nodding the head to relay agreement and expressing “no” using his hand

when answering to close-ended questions. Active listening was also emphasized

in order to anticipate the patient’s needs. For the altered mental status,

reorienting the patient to time, place and location was the utmost priority. The

patient was able regain level of consciousness but recurrent confusion was still

evident.

Student-centered objectives were met. The student nurses have provided

the necessary and quality nursing care of a patient with stroke. In addition, the

exposure taught them how to show emotional support as the client recuperates

from his illness. Nurse-patient interaction skills and assessment skills was

practiced effectively and efficiently by making sure that the physical assessment

done to the patient was done cephalocaudally. Nursing diagnosis with the

significantly related nursing care plan was formulated to performance of

appropriate nursing interventions to the patient were done. Necessary nursing

interventions needed to improve the condition of the patient were provided and

able to provide quality nursing care which is utmost concern every time in

handling a patient. The students have learned that in everything that one does,

safety always comes a priority, to avoid physical trauma and any untoward

injuries that may worsen a patient’s condition.

The student nurses have provided the necessary and quality nursing care

to improve the condition of patient J.M.B. In addition, the exposure at Ilocos

Training and Regional Medical Center, taught the students how to apply the

principles of nursing management to the care of a patient with cerebrovascular

disease.

On April 6, 2018, the student nurses still handled patient J.M.B and was

discharged with a final diagnosis of Transient Ischemic Attack.