NCP – Risk for bleeding

ASSESSMENT NURSING SCIENTIFIC GOAL & PLANNING NURSING RATIONALE EVALUATION

(12:00 pm, January DIAGNOSIS EXPLANATION INTERVENTION
3, 2022)
Subjective data: Altered comfort Nucleus pulposus Short-term goal: Independent: Independent: GOAL WAS MET
 Confusion related to pain as pushes out laterally, After 8 hours of nursing a) Prepare the 1. Assess
evidenced by: around the posterior intervention the client patient for a  Client may report Short-term goal:
Objective data: longitudinal ligament will be able to: surgical pain in the fingers, After 8 hours of
 Altered LOC with  Reports of a intervention like hips, knees, lower nursing intervention
of GCS: 6/15 decreased ability  Patient maintains a craniectomy. lumbar spine, and and monitoring :
 ICP increased to perform ADLs optimal cerebral cervical vertebrae.
 Pupil changes caused by L3 and L4 Lateral disc tissue perfusion, and b) Monitor  Patient manifested
 Widening pulse discomfort herniation absence of increasing intracranial  Client may have a better cerebral
pressure  Reports of pain, ICP. pressure (ICP) tried-and-true plan perfusion evidenced
 Abnormal tingling and  No decrease of 2 or utilizing a to implement relief. by the pts. ICP
respirations numbness more scores in the corneal catheter reading was 13
Glasgow coma scale device. Ensure mmHg.
 Bradycardia
Physically impinges level of that levels are  No decrease of 2 or
 Elevated
L4 spinal nerve roots consciousness. below 10 mm more scores in the
temperature
 Experiences no Hg.  Pain may be Glasgow coma scale
serious increases in associated with level of
intracranial pressure c) Help patient specific consciousness.
Inflamed and irritated during or following maintain the movements,  Experiences no
L4 nerve root care activities. head of the bed especially repetitive serious increases in
 Demonstrate elevated to at movements of the intracranial pressure
improved vital signs. least 30 involved joints. during or following
degrees, care activities.
Back Pain Long-term goal: ensuring that the  Demonstrate
After 3 days of nursing patient’s head is  Clients who have improved vital signs.
intervention patient will kept in neutral become
be able to: position. accustomed to
 Verbalize the use of living with chronic
pharmacological d) Assess the pain may learn to
and patient’s GCS tolerate basal levels
nonpharmacological score, including of discomfort and
pain relief strategies pupil size and only reports those
 Engage in desired reaction. discomforts that
activities without an exceed these
increase in pain e) Take note “normal” levels.
level. deviations in the
patient’s
 protective
reflexes like  The client may find
coughing, coping with a
swallowing, and progressive,
gagging. debilitating disease
difficult.
f) Monitor
Electrolytes and
Urine Output. 2. Heat reduces pain
through
g) Provide a calm improved blood flow
and safe to the area. Cold
environment. reduces pain,
Reorient the inflammation, and
patient during muscle spasticity
episodes of
confusion.
h) Little loose 3. Muscle spasms
may result from
tapes should poor body
be there to alignment, resulting
secure the in increased
discomfort.
endotracheal
tube. 4. Reducing other
factors that can
cause stress may
i) Hyperventilate
make it possible for
before the client to have
suctioning greater reserves of
emotional energy
through the for effective coping.
trachea
5. Exercise is
j) Avoid activities necessary to
and/or maintain joint
conditions that mobility.
may cause
elevations in ICP 6. Fatigue impairs the
such as: sudden ability to cope with
position discomfort.
changes,
 coughing, 7. Flexion of the joints
vomiting, may reduce muscle
valsalva spasms and other
maneuver, discomforts.
uncontrolled
pain or fever.
8. To provide relief
and reassurance for
Dependent: the client, as
indicated.
k) Administer
medication
therapy as
indicated as
ordered such as
steroids.
Dependent:

To reduce/relieve pain
of the patient.

NCP – Activity Intolerance

 ASSESSMENT NURSING SCIENTIFIC GOAL & PLANNING NURSING RATIONALE EVALUATION
(12:00pm January 3, DIAGNOSIS EXPLANATION DIAGNOSIS
2022)

Subjective data: Activity intolerance Adjusting posture and Short-term goal: Independent: Independent: Goal Met
related to gait to relieve pressure After 72 hours of  Assess the  Motivation and
 Lack of movement neuromuscular and to compensate for nursing intervention client’s ability to cooperation are Short-term goal:
 Decreased muscle dysfunction and the back pain the patient will: perform activities, enhanced if the After 72 hours of
strength decreased muscle  Client performs muscle power patient participates in nursing intervention
 Inability to walk strength & control the physical and reflexes goal setting. the patient is able:
 Loss of secondary to head mobility and  To perform the
consciousness concussion causing activities of  Stabilize the  Provides baseline activity as
decreased cerebral daily living with cervical spine & information. evidenced by
Objective data: perfusion Pressure and weight least amount of use log rolling increased muscle
move to the knees assistance. maneuver to shift strength and use
 GCS decreased: the client of adaptive
6/15  Adequate energy techniques for
 Confined to bed  Teach and reserves are needed ambulation.
 Decreased or provide range of during activity.
absent reflexes motion and
 Muscle power Knees are force to passive exercises  Patient with limited
decreased absorb the brunt of to all the joints activity tolerance
 Neuromuscular work regularly need to prioritize
conduction study important task first.
shows impaired  Provide sponge
neuromuscular ball and advice
function the client to  Assistive devices
Wear and tear squeeze it in the enhance the mobility
overtime erode hyaline hand regularly of the patient by
cartilage (articular) helping her
 Meet the overcome limitations.
activities of daily
living like  Assisting the patient
Decrease cartilage brushing, bathing, with ADLs allows
between the femur, and toileting at conservation of
tibia, and patella the bedside of the energy.
client.

 Provide back  Exercise maintains

Joint space narrowing care & turn muscle strength, joint
position every ROM, and exercise
two hourly in the tolerance.
 bed.

Joint movement with  Put on the

reduced lubrication bedside rails
stimulates joint
nociceptors  Orient client to
the environment
and if possible
take the client on
Pain with motion and a stretcher or
decreased range of wheelchair and
motion move around the
hospital once
clinically stable

 Educate on
different
ambulatory
assisting devices
like stretcher or
wheelchair
available to aid
the client in
movement

 Gradually assist
the client to sit up
in the bed then sit
near the sofa and
chair and slowly
aid in ambulation
 NCP – Hyperthermia

ASSESSMENT NURSING SCIENTIFIC GOAL & PLANNING NURSING RATIONALE EVALUATION

(12:00 pm January 3, DIAGNOSIS EXPLANATION INTERVENTION
2022)
Subjective data: Impaired Skin Integrity Back pain Short–term goal: Independent: Independent: Partially Met:
r/t skin destruction After 48 hours of 1) Heat-related illness
 Disoriented secondary to vehicular nursing intervention  Assess adequacy occurs when the After 2 days span of
accident the patient will be able of blood supply body’s care our client was
Objective data: Immune response to: and innervation of thermoregulatory able to demonstrate
Has visible multiple the affected system fails.
progressive
 Abrasion of abrasion on skin, tissue.
appears redness on Increase body
improvement in wound
wounds noted  The patient will  Inspect wounds or 2) Exposing skin to or lesion healing as
 moist wound site and moist wound. temperature maintain an intact lesions daily for room air decreases
Elevated temperature tissue integrity  heat and increases evidence by:
 redness on site changes.
 Elevated was notes as  The patient will  Promote good evaporative
temperature: 39 °C evidenced by 39 °C. verbalize a plan of nutrition with cooling. a. presence of
care to maintain adequate protein abrasions but minimal
uncompromised such as fish. 3) A tepid sponge redness noted on the
tissue integrity   Inspect wounds or bath is a non- surface of the wound;
 The patient will be lesions daily for pharmacological
free of pain  changes. measure to allow b. demonstrate
evaporative
 Promotes timely behavior/lifestyle
 The patient will cooling.
interventions/ changes to promote
experience an
 improved wound revision of plan of 4) Surface cooling by
healing process  care. placing ice packs healing and prevent
 Promote good in the groin area, complications; patient
 The patient will nutrition with axillae, neck, and
verbalize and was seen guarding
adequate protein torso is an
demonstrate behavior on the site
such as fish. effective way of
wound care cooling the core
 Provide adequate
correctly temperature.  Objective data: •
periods of rest
Altered LOC with
 Demonstrate and sleep.
of GCS: 6/15 •
behavior/lifestyle  Instruct to practice
aseptic technique. 5) Prolonged
Pupil changes •
changes to
exposure to ice Widening pulse
promote healing  Encourage early
mobility. Provide can damage the pressure •
and prevent
complications position changes. skin. Cover ice Abnormal
 Educate packs with a towel respirations •
importance of and regularly Bradycardia •
early detection adjust the site of Elevated
and reporting of application to temperature
changes in mitigate skin
condition damage.  Appears to be
 Emphasize need confused with a GCS
for adequate 6) Most efficient score of 6/15. Has
nutritional or fluid noninvasive decreased muscle
intake. technique for strength, reflexes, and
lowering core body impaired
temperature. neuromuscular
function.
7) Room temperature
may be
accustomed to
near normal body
temperature, and
blankets and linens
may be adjusted
as indicated to
regulate the
patient’s
temperature.

8) Promotes comfort
and helps prevent
chilling since
 diaphoresis occurs
during
defervescence. 
Dependent:
Administer 9) If the client is alert
paracetamol as enough to swallow,
prescribed. provide cool liquids
to help lower the
body temperature.
Additionally, if the
patient is
dehydrated or
diaphoretic, fluid
loss contributes to
fever.

Dependent:
To reduce the client’s
temperature