NURSING CARE PLAN-FALL 2018

Student: JULIA ARIDI Date: 21-11-2018 Unit: 4TH FLOOR

(Total= 5 points)
 Patient Initials: I.M.H Bed No. __406 __
Medical history: Hypertension, Dyslipidemia
Case No. :180036047 Admission Date : 6-11-2018

Diet: Gluten and lactose free/ low salt low fat Surgical history: Appendectomy, Lithotripsy
Nursing Diagnosis Scientific Rationale for Nursing Diagnosis Expected Outcome Nursing Intervention Scientific Rationale for Criteria for Evaluation of
(3pts)Activity: Complete bed rest
(10pts) (3pts) (13pts) Nursing Intervention (13pts) Expected outcome with
justification (3pts)
Closed (blunt) brain injury occurs At the end of the Assessment:
Intravenous Therapy: NSS 1L/24 hr Medications
Acute confusion whenRate= 40cc/hr
the head accelerates and then shift, the patient 1. Assess patient’s 1. Delirium
 Rinacidin mouth wash BID 9am 9pm
related to multi rapidly decelerates or collides with will:  Nexium 40mg
behavior and PO BID 6am 6pm always involves
 Depakene chrono 750mg PO BID 9am 9pm
contusion and another object and brain tissue is -Have diminished  cognition
Omnic ocas 0.4mg PO BID 9am 9pm
acute change in
Allergies: Gluten and lactose  Medihoney barrier on bony prominence BID 9am 9pm
very small damaged but there is no opening episodes of systematically and mental status;
 Stilnox 10mg ½ tab PO daily 9pm
subarachnoid through the skull and dura. In delirium  Lovenox 40mg S/C daily 2pm
continually therefore,
Treatments  Perfalgan 1g IV Q6 hrs forPain
hemorrhage
 assess VS cerebral
Q 4hrscontusion, a moderate to - regain normal  throughout the day
HGT BID 8am- 11am knowledge of
 toPatient identification
secondary severe head injury, the brain is reality orientation the patient’s
and night as
 Perform HH
traumatic
 brain
monitor bruised
IV site and damaged in a specific and level of appropriate. baseline mental
 follow up
injury evidenced labbecause
area results of severe acceleration- consciousness status is key in
 pain management
by CT-Brain in deceleration force or blunt trauma. - initiate assessing
 administer meds as prescribed
additionto perform The
PA impact of the brain against the lifestyle/behavior delirium.
 in
fluctuation HGT BID (Inform
skull leads MD
to a if HGT <80 or >200)
contusion. changes to prevent
 Risk for falls and pressure injury precautions
cognition, Contusions are characterized by
 Elastic stocking or minimize 2. Evaluate extent of 2. This should be
episodes of Tractionalteration
5kg left hip (Do not move left hip)
in consciousness recurrence of impairment in done to
 Asses patient’s cognition and behavior
confusion, and associated with stupor and the problem orientation, attention determine
increased confusion are more often associated span, ability to degree of
agitation and with hemorrhage and destruction of follow directions, impairment.
restlessness. the reticular activating fibers send/receive
altering arousal. communication,
Reference: Hunkle, J. L., Brunner, appropriateness of
L. S., Cheever, K. H., & Suddarth response.
D. S. (2014). Brunner & Suddarths 3. Evaluate and report
textbook of medical surgical possible
nursing. physiological
P:1911-1940 changes 3. Such changes
(e.g., sepsis, hypogly may be
cemia, hypotension, contributing to
infection, changes in confusion and
temperature, fluid must be
and electrolyte corrected.
imbalances,
medications with
known cognitive and
psychotropic side
effects).

INTERVENTIONS:
1. Encourage
family/SO(s) to
participate in
reorientation as well 1. The confused
as providing patient may not
ongoing input. completely
understand what is
happening.
Presence of family
 and significant
others may enhance
2. Provide for safety the patient’s level
needs (e.g., of comfort.
supervision,
siderails, seizure 2. This is to prevent
precautions, placing untoward incidents
call bell within and to promote
reach, positioning safety.
needed items within
reach/clearing traffic
paths, ambulating
with devices).
3. Maintain normal
fluid and electrolyte
balance;
establish/maintain
normal nutrition,
body temperature, 3. To treat underlying
oxygenation (if causes of delirium
patients experience in collaboration
low oxygen with the health care
saturation treat with team.
supplemental
oxygen), blood gluc
 ose levels, blood
pressure.
4. Identify self by
name at each
contact; call
the patient by his or
her preferred name.
4. Appropriate
communication
techniques for
patients at risk for
5. Identify, evaluate, confusion.
and treat pain
immediately. 5. Unmanaged pain is
a potential cause for
delirium.
6. Maintain patient’s
sleep-wake cycle as 6. Acute confusion is

normal as possible accompanied by

(e.g., avoid letting disruption of the

the patient take sleep-wake cycle.

daytime naps, avoid

waking patients at
night, give sedatives
but not diuretics at
bedtime, provide
pain relief and
 backrubs).
7. Give simple
directions. Allow 7. This
sufficient time for communication
patient to respond, to method can
communicate, to reduce anxiety
make decisions. experienced in
strange
environment.

8. Assist the family and

significant others in
developing coping 8. The family needs to
strategies. let the patient do all
that he can do to
maximize the
patient’s level of
functioning and
Teaching quality of life.
1. Teach family to
recognize signs of
early confusion and 1. Early intervention
seek medical help. prevents long-term
complications.