MISSION

VISION MABINI COLLEGES provides quality instruction,

MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Ineffective cerebral tissue After performing the Assess factors related to  Patient will maintain
‘Nawalan na lang po siya ng malay perfusion related to nursing intervention, the individual situation for usual/improved level
habang naliligo.” cerebrovascular spasm client will be able to decreased cerebral of consciousness,
As verbalized by the client’s husband maintain vital signs within perfusion and potential for cognition, and
normal range and increased ICP. motor/sensory
Objective: improve level of function.
Vital signs taken as follows: consciousness, cognition RATIONALE  Patient will
 T- 37°C and motor/sensory  Assessment will demonstrate stable
 BP-200/120mmHg function. determine and vital signs and
 RR- 20 bpm influence the choice absence of signs of
 CR-60 bpm of interventions. increased ICP.
 O2Sat- 92% Deterioration in  Patient will display no
 GCS- M1, V1, E1 = 3/15 neurological signs further
or failure to improve deterioration/recurren
 Altered level of after initial insult ce of deficits
consciousness may reflect
decreased
 Restlessness intracranial adaptive
capacity requiring
patient to be
transferred to critical
area for monitoring
of ICP, other
therapies

Closely assess and monitor

neurological status
frequently and compare
with baseline.
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

RATIONALE:
 Assesses trends in
level of
consciousness
(LOC) and potential
for increased ICP
and is useful in
determining
location, extent, and
progression of
damage. May also
reveal presence of
TIA, which may
warn of impending
thrombotic CVA.

Changes in blood pressure

compare BP readings in
both arms.

RATIONALE:
 Fluctuations in
pressure may occur
because of cerebral
injury in vasomotor
area of the brain.
Hypertension or
postural
hypotension may
have been a
precipitating factor.
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

Hypotension may
occur because of
shock (circulatory
collapse). Increased
ICP may occur
because of tissue
edema or clot
formation.

Heart rate and rhythm,

assess for murmurs.

RATIONALE:
 Changes in rate,
especially
bradycardia, can
occur because of
the brain damage.
Dysrhythmias and
murmurs may
reflect cardiac
disease, which may
have precipitated
CVA (stroke after MI
or from valve
dysfunction).

Respirations, noting
patterns and rhythm
(periods of apnea after
hyperventilation), Cheyne-
Stokes respiration.

RATIONALE:
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

 Irregularities can
suggest location of
cerebral insult or
increasing ICP and
need for further
intervention,
including possible
respiratory support.

Assess for nuchal rigidity,

twitching, increased
restlessness, irritability,
onset of seizure activity.

RATIONALE
 Indicative of
meningeal irritation,
especially in
hemorrhage
disorders. Seizures
may reflect
increased ICP or
cerebral injury,
requiring further
evaluation and
intervention.

Therapeutic Interventions

Position with head slightly

elevated and in neutral
position.
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

RATIONALE

 Reduces arterial
pressure by
promoting venous
drainage and may
improve cerebral
perfusion

Maintain bedrest, provide

quiet and relaxing
environment, restrict
visitors and activities.
Cluster nursing
interventions and provide
rest periods between care
activities. Limit duration of
procedures.

RATIONALE

 Continuous
stimulation or
activity can increase
intracranial pressure
(ICP). Absolute rest
and quiet may be
needed to prevent
rebleeding in the
case of
hemorrhage.

Administer supplemental
oxygen as indicated.
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

RATIONALE:
 Reduces
hypoxemia.
Hypoxemia can
cause cerebral
vasodilation and
increase pressure
or edema formation.

Prepare for surgery, as

appropriate:
endarterectomy,
microvascular bypass,
cerebral angioplasty.

RATIONALE:

 May be necessary
to resolve situation,
reduce neurological
symptoms of
recurrent stroke.

NURSING CARE PLAN

 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

EVALUATION
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION
Subjective: Ineffective airway After performing nursing Assess respiratory rate The client maintains
clearance R/T inability to intervention, the client pattern, lung sounds, lung patent airway as
clear respiratory will be able to maintain expansion, signs of tissue evidenced by clear lung
secretions. patent airway and hypoxia, cyanosis, pallor; sounds.
V/S taken as follows: maintain vital signs presence of airway secretions;
 T-37°C within normal range. occlusion of oropharynx by Vital signs within normal
 BP-160/100 mmHg epiglottis or tongue; aspiration range.
 RR-25 bpm of vomitus or oral secretions.
 CR-80 bpm
 O2Sat- 87% Rationale:
Provides data for planning
 CT scan (hemorrhagic pons) care.
 ECG: ischemia lateral wall
 Increased FBS Elevate had of bed to 30-
 • Increased Lipid profile degree angle or place client in
lateral or semi prone position.

Rationale:
Head elevation prevents
aspiration. Lateral position
permits the jaw and tongue to
fail forward, thus promoting
drainage of secretions.

Insert oral airway (if tongue is

paralyzed or is obstructing the
airway).

Rationale:
Prevents obstruction of
airway; obstructed airway
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

leads to cerebral hypoxia

which increases ICP.

Suction airway intermittently.

Rationale:
In the absence of cough and
swallowing reflexes,
secretions rapidly accumulate
in the posterior pharynx and
upper trachea and can lead to
aspiration. Intermittent
suctioning prevents this.

Administer humidified oxygen

to the airway before and after
suctioning.

Rationale:
Prevents hypoxia which may
be caused by sucking out of
air while suctioning.

Initiate chest physiotherapy

and postural drainage (unless
contraindicated)

Rationale:
promotes pulmonary hygiene

Prepare for endotracheal

intubation or tracheostomy

Rationale:
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

allows efficient removal of

tracheobronchial secretions
and protects the airway from
aspiration.

Connect the client to

mechanical ventilator as
needed.

Rationale:

Helps maintaining
oxygenation when
spontaneous respiration is not
possible.

Increase amount of fluids

administered at least 2.5 litre
per day.

Rationale:
loosens airway secretions
promoting easy removal.

Auscultate chest at least every

8 hours.

Rationale:
helps detect adventitious
breath sounds or absent
breath sounds.

- Monitor ABG measurements.

 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

Rationale:
help detect complications of
respiratory problems at the
earliest.