Zaraspe, Ma. Carla Ashley E.

BSN 3 November 21, 2017

Patient’s initials: R.D Age/Sex: 52/M

Diagnosis: CVA (Cerebrovascular accident) Ward/Bed: 505 3G

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
Subjective: Increased body After 8 hours of Monitor and record vital To establish a baseline data
“Lagi naman po temperature r/t nursing signs particularly
siyang nilalagnat.” cerebral trauma intervention, the temperature and PR
As verbalized by patient’s body
patient’s temperature will Advised patient’s To reduce body temperature
companion reduce within companion to apply tepid
normal range sponge bath especially in
Objective: forehead, axilla and groin
Febrile (T: area
38.4°C)
PR: 145bpm Advise patients’ relative to To provide comfort
Profuse sweating change patients clothes into
Hot to touch loose fitting clothes
Restless
Lethargic
 Subjective: Activity intolerance Short term: After 8 Assist patient to reposition To promote optimum function
“Hinang hina na r/t generalized hours of nursing self every 2 hours and prevent impaired skin
talaga ang katawan weakness intervention, the integrity
ng tatay ko simula secondary to CVA patient is willing to
pa nung kinonfine participate in To avoid stiffness of joints
sya dito sa ospital.” necessary activities Assist patient in passive
As verbalized by range of motion exercise
the patient’s Long term:
companion The patient will be To avoid further physical injury
able to avoid joint Provide safety at all times
Objective: stiffness by raising side rails and
Limited ROM instructing companion
Decreased muscle
strength
Difficulty turning
Stiffness in upper
and lower
extremities

Subjective Risk for aspiration After 8 hours of Elevate the patient’s head To decrease risk of aspiration
“Dalawang beses r/t ineffective nursing during NGT feedings
po siya sumuka.” swallowing intervention, there
As verbalized by mechanism will be a decreased Identify whether the NGT
patient’s or no risk of tube is still patent
companion aspiration
Keep suction available at
Objective: bedside

Presence of
tracheostomy tube

Occasional cough
 Exhibits difficulty
of swallowing

Inability to produce
verbal sound

Zaraspe, Ma. Carla Ashley E. BSN 3 November 21, 2017

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
Subjective: Altered body After 8 hours of nursing Monitor and record vital signs To establish a baseline
“Parang mainit temperature r/t intervention, the particularly temperature data
siya.” As verbalized cerebral trauma patient’s body
by the patient’s temperature will reduce Advise patient’s companion to
companion within normal range apply tepid sponge bath
especially in forehead, axilla To reduce body
and groin area temperature
Objective:
Febrile (T: 37. 9°C) Advise patients’ relative to
Facial grimace and change patients clothes into
making sounds loose fitting clothes
Irritable
Profuse sweating To provide comfort
Teary-eyed
 Subjective: Ineffective breathing After 8 hours of nursing Assess patients’ respiratory To determine the problem
“Para siyang pattern r/t presence intervention, the patient status and intervene
nalulunod” as of secretion will be breathing clearly appropriately
verbalized by the
patient’s Auscultate for adventitious
relative sounds

Objective: Perform suctioning as needed To aid the patient in

(+) Crackles removing stocked
(+) Secretions secretions
Lethargic
With chest Elevate patient’s head to To promote expansion of
retractions moderate high back rest the lungs, ventilation and
Hooked with O2 via avoid aspiration
nasal cannula Provide oral care
To remove excess mucous
in mouth

Patient’s initials: F.A Age/Sex: 39/M

Diagnosis: CVD Bleed Ward/Bed: 505 3F
Patient’s initials: R.B Age/Sex: 80/M
Diagnosis: Acute Kidney Injury secondary to RPGN vs. leptospirosis Ward/Bed: 505 3H

DISCHARGE PLANNING
Medications: Instruct patient of take home medications
Ceftriaxione 2 grams once a day
Omeprazole 10mg thrice a day
CaCO3 1 tab thrice a day
NaHCO3 thrice a day
FESO4 + FA thrice a day
Exercise: Encourage patient to continue usual exercise routine
Treatment: Instruct patient to strictly follow hemodialysis schedule (Three times a week
Health teaching: Advise patient to maintain hygiene and clean environment and avoid stagnant and flooded areas.
Outpatient: Advise the patient to report if there is leakage of blood or fluid, tenderness, redness or odor in insertion site.
Instruct to return to OPD for follow up check up schedule during Fridays from 1 to 3pm
Diet: Encourage patient to increase oral fluid intake
 Instruct patient to limit eating food rich in sodium
Spiritual: Assist patient in his spiritual beliefs