Submitted by: Pauline R.

Basi
NDB2

CVA
ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTION RATIONALE EVALUATION
PROBLEM
Subjective: Formation of aneurysm or STO:  Determine factors  Influences choice STO:
No subjective cues since sac around the brain will Within 8 hours of nursing related to individual of interventions. Goal met. After 8 hours of
patient is unconscious cause interruption of blood intervention, the client’s situation, cause for Deterioration in effective nursing
flow or blockage in the blood pressure will coma, decreased neurological signs intervention, the client’s
blood vessels of the brain. decrease from 180/100 to cerebral perfusion, and symptoms or blood pressure was
Objective: Insufficient arterial blood 140/80. and potential for failure to improve reduced from 180/100 to
 GCS of 7/15 flow causes decreased increased ICP. after initial insult 140/80.
E1V2M4 nutrition and oxygenation at LTO: may reflect
 Hemiplegia the cellular level. Once Within 2-3 weeks of nursing decreased LTO:
 Pale nailbeds there’s a reduction of intervention, the client will intracranial Goal partially Met. After 2-3
 Both pupils are cerebral blood flow and maintain maximum tissue adaptive capacity, weeks of effective nursing
nonreactive to decrease oxygenation in perfusion to vital organs, as which requires that intervention, the client
light the brain, Decreased evidenced by warm and dry client be admitted maintained maximum
 With blood Cerebral Tissue perfusion skin, present and strong to critical care area tissue perfusion to vital
pressure of happens and will manifest peripheral pulses, vitals for monitoring of organs, as evidenced by
180/100 signs and symptoms such within patient’s normal ICP and for warm and dry skin, present
Nursing Diagnosis: as altered level of range, balanced I&O, and specific therapies and strong peripheral
Decreased Cerebral Tissue consciousness and normal ABGs. geared to pulses, vitals within
Perfusion related to changes in motor and maintaining ICP patient’s normal range,
interruption of blood flow as sensory response. within a specified balanced I&O,
manifested by altered level range. If the stroke normal ABGs, scored 1 on
of consciousness, changes is evolving, client the scoring of level of
in motor and sensory can deteriorate consciousness or not alert
response. quickly and require and is arousable by minor
repeated stimulation.
 assessment and
progressive
treatment. If the
stroke is
“completed,” the
neurological deficit
is nonprogressive,
and treatment is
geared toward
rehabilitation and
preventing
recurrence

 Monitor and  Assesses trends in

document LOC and potential
neurological status for increased ICP
frequently and and is useful in
compare with determining
baseline location, extent,
and progression or
resolution of CNS
damage. May also
reveal TIA, which
may resolve with
no further
symptoms or may
precede thrombotic
CVA.

 Monitor vital signs

noting:  Fluctuations in
Hypertension or pressure may
hypotension; occur because of
 compare blood cerebral pressure
pressure (BP) or injury in
readings in both vasomotor area of
arms. the brain.
Hypertension or
hypotension may
have been a
precipitating factor.
Hypotension may
follow stroke
because of
circulatory
collapse.

 Heart rate and  Changes in rate,

rhythm; auscultate especially
for murmurs. bradycardia, can
occur because of
the brain damage.
Dysrhythmias and
murmurs may
reflect cardiac
disease, which
may have
precipitated CVA,
for example, stroke
after MI or from
valve dysfunction.

 Irregularities can
 Respirations, suggest location of
noting patterns and cerebral insult or
rhythm—periods of increased ICP and
apnea after need for further
hyperventilation, intervention,
Cheyne-Stokes including possible
respiration respiratory support

 Pupil reactions are

 Evaluate pupils, regulated by the
noting size, shape, oculomotor (III)
equality, and light cranial nerve and
reactivity. are useful in
determining
whether the
brainstem is intact.
Pupil size and
equality is
determined by
balance between
parasympathetic
and sympathetic
enervation.
Response to light
reflects combined
function of the
optic (II) and
oculomotor (III)
cranial nerves
 Reduces arterial
 Position with head pressure by
slightly elevated promoting venous
and in neutral drainage and may
 position. improve cerebral
circulation and
perfusion

 Maintain bedrest,  Continual

provide quiet stimulation can
environment, and increase ICP.
restrict visitors or Absolute rest and
activities, as quiet may be
indicated. Provide needed to prevent
rest periods recurrence of
between care bleeding, in the
activities, limiting case of
duration of hemorrhagic stroke
procedures.

 Reduces
 Administer hypoxemia.
supplemental
oxygen, as
indicated.

DM
 ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTION RATIONALE EVALUATION
PROBLEM
Subjective: Amputation of the limbs is STO: Encourage patient to To prevent stump trauma STO:
“Di na ako makalakad dahil the result of trauma, Within 8 hours of nursing perform prescribes Goal met. the client
sa tinanggal na isang paa peripheral vascular intervention, the client will exercises verbalized understanding of
ko” disease, tumors and verbalize understanding of situation and risk factors,
congenital disorders. situation and risk factors, Provides an opportunity to individual therapeutic
Impaired physical mobility individual therapeutic Provide stump care on a evaluate healing and note regimen and safety
Objective: can happen to clients who regimen and safety routine basis: inspect the complications (unless measures.
 With have diabetes mellitus and measures. area, cleanse and dry covered by immediate
functional apparently that can cause thoroughly, and rewrap prosthesis). Wrapping
level of 2 amputation to lower limbs. LTO: stump with an elastic stump controls edema and LTO:
 Requires Within 7 days of nursing bandage or air splint, or helps form stump into a Goal Met. After 7 days of
assistance intervention, the client will apply a stump shrinker conical shape to facilitate nursing intervention, the
from another participate in activities of (heavy stockinette sock), the fitting of the prosthesis. client participated in
person daily living and desired for “delayed” prosthesis activities of daily living and
 Unable to activities. Measurement is done to desired activities.
position one estimate shrinkage to
lower limb on Measure circumference ensure proper fit of sock
uneven periodically and prosthesis
surface
 Postural Edema will occur rapidly,
instability Rewrap stump immediately and rehabilitation can be
 With with an elastic bandage, delayed
amputated left elevate if “immediate or
lower limb early” cast is accidentally
Nursing Diagnosis: dislodged. Prepare for
Impaired physical mobility reapplication of the cast.
related to loss of limb; pain
discomfort and perceptual
impairment as evidenced Assist with specified ROM
by reluctance to attempt a exercises for both the Prevents contracture
movement. affected and unaffected deformities, which can
limbs beginning early in the
postoperative stage.
Encourage active and
isometric exercises for the
upper torso and unaffected
limbs.
Demonstrate and assist
with transfer techniques
and use of mobility
aids like trapeze, crutches,
or walker.
Assist with ambulation.
Refer to the rehabilitation
team.
develop rapidly and could
delay prosthesis usage.
Increases muscle strength
to facilitate transfers and
ambulation and promote
mobility and more normal
lifestyle.
Facilitates self-care and
patient’s independence.
Proper transfer techniques
prevent shearing abrasions
and dermal injury related to
“scooting.”
Reduces the potential for
injury. Ambulation after
lower-limb amputation
depends on the timing of
prosthesis placement.
Provides for the creation of
exercise and activity
program to meet individual
needs and strengths, and
identifies mobility functional
aids to promote
independence. Early use of
a temporary prosthesis
 promotes activity and
enhances general well-
being and positive outlook.

Reduces pressure on skin

Provide foam or flotation and tissues that can impair
mattress. circulation, potentiating the
risk of tissue ischemia and
breakdown

CKD
 ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTION RATIONALE EVALUATION
PROBLEM
Subjective: Acute pain is an STO: Assessment STO:
“medjo masakit yung unpleasant sensory and Within 8 hours of nursing Perform an assessment of of pain Goal met. After 8 hours of
naoperahan sakin para daw emotional experience intervention, the client will pain to include location, experience is nursing intervention, the
kasi sa dialysis ko” arising from actual or repost pain is relieve or characteristics, onset/ the first step client repost pain is
Describe pain as throbbing and potential tissue damage or controlled duration, frequency, in planning relieved or controlled
sharp. Rated pain 7/10. described in terms of such LTO: quality, severity, grimacing pain
damage; sudden or slow Within 7 days of nursing (0 – 10 scale) management LTO:
Objective: onset of any intensity from intervention, the client will strategies. Goal Met. After 7 days of
 Guarding mild to severe with an verbalize sense of control The most nursing intervention, the
behavior on the anticipated or predictable of response to acute reliable client verbalized sense of
AVF noted end and a duration of less situation and positive source of control of response to
 Facial grimace than six months. outlook for the future. information acute situation and
noted about the positive outlook for the
 Weak in . pain is the future.
appearance patient.
 Irritable Descriptive
 With vital signs of: scales such
BP:140/180 as a visual
PULSE: 100 analogue can
RESPIRATION:20 be utilized to
distinguish
the degree of
pain.

Nursing Diagnosis:
Acute pain related to physical
injury agent as manifested by Assess for signs and Attention to
changes in vital signs symptoms relating to pain associated
signs may
help the
nurse in
 evaluating
pain

Observations
Observed for non-verbal may not be
cues congruent
with verbal
reports or
may be only
indicator
present when
the client is
unable to
verbalize

Giving oral
medications
Administer pain medication such as
as prescribed by the NSAID’s may
physician relieve pain

For relaxation
and to help
Provide comfort measures, lessen the
quiet environment and pain
calm activities
 Prevents
boredom,
Encourage diversional reduces
activities and relaxation muscle
techniques such as tension and
focused breathing and an increase
imaging muscle
strength

One’s experiences of pain

may become exaggerated
as a result of exhaustion.
Provide rest periods to Pain may result in fatigue,
promote relief, sleep,
which may result in
and relaxation.
exaggerated pain. A
peaceful and quiet
environment may facilitate
rest.