COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES

NURSING DEPARTMENT
MIGUEL Z. ZUBIRI
BSN 3D

Activity#3:NURSING CARE PLAN

ASSESSMENT EXPLANATION OF OBJECTIVE INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Short term: After

6-12 hours of
nursing
intervention, the
patient will be
able to improved
her level of
consciousness

Subjective: Arterial wall Long term: After Independent: Short term After 12
weakens 6-7 days of hours of nursing
-Reports headache the treatment, - Assess airway - Assess factors related to intervention, the
day before she became patency and decreased cerebral
patient will patient was able to
unconsciousness display respiratory pattern. perfusion and the potential improved her level
intracranial for increased intracranial
-No history of aneurysm neurological signs of consciousness
within normal pressure (ICP)
hypertension or other . Goal was met
health problems range. - The extensive neurologic
sudden entry of - Assess factors examination will help guide Long term: After 7
Objective: therapy and the choice of days of treatment,
related to decreased
-Arrived at the ER, blood cerebral perfusion interventions. patient will display
unconscious and the potential for neurological signs
increased within normal
-Has 5 score in Glasgow intracranial pressure range. Goal was
Coma Scale (ICP) met.
-Diagnostic test ruptured aneurysm
- Monitor
revealed a respirations, noting
subarachnoid patterns and rhythm,
hemmorage - Irregular respiration can
Cheyne-Stokes
suggest the location of
Vital Signs as follows: Increased respiration.
cerebral insult or increasing
intracranial ICP and the need for further
-BP: 150/80 mm Hg pressure intervention, including
-RR: 16 breaths/min possible respiratory support.

HR: 55 bpm, Collaborative:

Temp: 101° F (38.3° C) -Administer

Increasing risk for
medications
ineffective cerebral
perfusion
Nursing diagnosis:
-Prepare client for
- Risk for ineffective surgery.
cerebral tissue tissue
perfusion related to
haemorrhage