Foundation University

COLLEGE OF NURSING

Dumaguete City

NCP

Prepared by:
Catipay, Menutska, SN/FUCN

Noted by:
Jo-an Flores Pasinabo, RN

Date:
December 5-7, 2022
 Foundation University

COLLEGE OF NURSING

Dumaguete City

NURSING CARE PLAN FORM

Patient’s Name: Mengollo, Enriqueta C. Admitting Diagnosis/CC: Right-Sided Weakness, ; Metastatic Pneumonia (infection spread to another part of the body)
Age: 52 years old Sex: Female
Room No: 3 Date: December 5-7, 2022

ASSESSMENT CUES NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Ineffective tissue After 3 days of nursing Independent: - Goal-partially met.
“Mokalit ra ko og perfusion related to interventions, the patient Patient was able to
kalipong mam unya cerebral edema will be able to demonstrate 1. Monitor vital signs and - To determine if demonstrate
labad ako ulo”, as secondary to increased perfusion, as neurological status. there is increased increased perfusion,
verbalized by the metastatic process. evidenced by: in blood pressure, as evidenced by
patient. as it indicates absence of
- Right-sided - Vital signs within increased drowsiness,
weakness normal limits intracranial dizziness; patient’s
- Drowsiness - Motor, cognitive and pressure (ICP) RR returned to
- Lightheadedness sensory function are normal (from 24 to
acceptable for age 2. Observe for increasing - To know if infection 19 cpm); improved
- Absence of edema signs of intracranial is too high already, sensory function is
in any parts of the pressure, such as and if symptoms displayed; and
body drowsiness and lead to potential understood
headache. damage teachings given
 Foundation University

COLLEGE OF NURSING

Dumaguete City

Objective: - Absence of through

- Changes in drowsiness, 3. Maintain repositioning - To promote venous verbalization of
sensory dizziness and and elevation of head drainage from understanding of
responses lightheadedness 30°, avoid neck flexion head, thereby risk factors, therapy
- Pallor - Verbalization of and hip flexion. reducing cerebral regimen and when
- Dry lips understanding of congestion and to contact health
- High WBC: risk factors, therapy edema care provider for
36.30 regimen and when further treatment
Dependent:
CT-Scan Brain Result: to contact health
- Tiny hypodense care provider for
1. Administer oxygen as - To reduce hypoxia,
foci with further treatment
ordered by the physician. which can elevate
extensive edema
ICP and promote
in both parietal
cerebral
lobes, due to
vasodilation
neoplastic or
metastatic
2. Administer anthelmintic - To treat disease,
process
(brain foci detected), manage conditions
- VS taken as
corticosteroid, and other and relieve
follows:
medications, as symptoms
T: 36.2 °C
prescribed by the
P: 61 bpm
physician.
R: 24 cpm
O2Sat: 96%
BP: 130/80
mmHg
-
Foundation University

COLLEGE OF NURSING

Dumaguete City

Collaborative:

1. Collaborate with - To prevent bed

significant others sores
regarding on the hourly - To prevent further
positioning changes and development of
other symptom relief illness
support.