NURSING CARE PLAN
Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0)
Subjective/Objective cues:
Nursing Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
Subjective cues:None-with ET tube attached to mechanical ventilator
Objective cues: With pupillary
size of 4 mm on right eye, 2 mm on left eye, both eyes with negative reaction to light
Muscle grade of 1/5 for slight muscle contraction on all extremities, no joint motion.
With GCS of 6 (best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs
Ineffective Cerebral Tissue Perfusion related to the interruption of the blood flow to the brain.
General:Within 2 weeks of medical and nursing interventions, client will be able to improve level of consciousness.
Specific:Within 1 day of medical and nursing interventions, client will be able to manifest:
Improve/Stable level of consciousness
Improve/Stable GCS score
No pupillary changes, seizures, widening of pulse pressure, irregular respirations, hypotension and bradycardia.
Independent:Assessment
Assess mental status and changes in the level of consciousness
Therapeutic Position client in
low-fowler’s position (30 degrees)
Avoid extreme rotation of the neck
Avoid extreme hip flexion
To check for affected cranial nerve functions in the brain (for GCS); check for cerebral hypoperfusion and hypoxia.
Help venous drainage from the brain and promote brain expansion.
This will compress the jugular veins leading to an increased intracranial pressure.
Increase in intra-abdominal and intra-thoracic pressure leading to increased intracranial
GCS of 5 (best eye opening-1, none; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)
Patient is placed in low-Fowler’s position; made comfortable in bed and adjusted pillows
Patient is monitored frequently; positioned head and neck cautiously and placed a pillow on side for support
Patient is repositioned cautiously and provided with pillows for support
to pain) Babinski reflex-
positive, and oculocephalic reflex-negative
Maintain patent airway
Dependent:
Administer medications such as diuretics (e.g. Mannitol) and anticonvulsants (e.g. Amlodipine, Verapamil)
Collaborative:
Review pulse oximetry
Restore or maintain fluid balance
pressure.
Prevents build up of secretions leading to increase in carbon dioxide and intracranial pressure.
Diuretics are used and needed to decrease cerebral edema and anticonvulsant medications
Hypoxia is associated with reduced cerebral tissue perfusion.
It maximizes cardiac output and prevents decreased cerebral perfusion associated with hypovolemia.
ET tube placement is monitored if securely attached to patient at the appropriate level of 21 cm; suctioned frequently for secretions
Mannitol 75 cc was given intravenously to patient; antihypertensives such Amlodipine 20 mg per tablet and Verapamil 10 mg per tablet was also given to patient
Oxygen saturation patient ranges 98-99%
With IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient, with a rate of 21 drops per minute
Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0)
Subjective/Objective cues:
Nursing Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
Subjective cues:None- with ET tube attached on mechanical ventilator
Objective cues: Adventitious
breath sounds heard at left anterior lung such as ronchi and wheezing
Presence of whitish, tenacious secretions approximately 20 cc
Decreased level of consciousness (GCS of 6: best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)
Ineffective airway clearance maybe related to hypoventilation secondary to brain stem injury
GeneralWithin 1 week of medical and nursing intervention, client will be able to mobilize secretions.
SpecificWithin 1 day of medical and nursing interventions, client will be able to manifest:
Clear breath sounds
Decreased secretions
IndependentAssessment
Assess respiration and breath sounds, noting rate and sounds (e.g. tachypnea, stridor, crackles, wheezes)
Evaluate cough/gag reflex and swallowing ability
Assess airway for patency
Assess changes in mental status
These signs and symptoms are indicative of respiratory distress and/or accumulation of secretions.
To determine ability to protect own airway
Maintaining the airway is always first priority, especially in cases of trauma.
Lethargy and somnolence are late signs
Respirations range between 16-21 breaths per minute, regular in rate and rhythm; adventitious breath sounds heard over left anterior lung, including ronchi and wheezing soundsPatient exhibits swallowing and gag reflexes; with absent cough reflex
Placement of ET tube on patient is monitored frequently at the appropriate level of 21 cm; suctioned frequently for presence of secretions.Patient is GCS 5 (no eye opening-1, with ET tube attached-1, and flexes arms and extends legs to painful stimuli-3)
Note presence of sputum, assess quality, color, amount, odor and consistency.
Therapeutic Elevate head of
bed and reposition every 2 hours and as needed.
Routinely check the patient’s position so he does not slide down in bed.
Use humidifier.
Institute suctioning of the airway.
Abnormalities maybe a result of infection. A sign of infection is discolored sputum.
To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments.
This prevents abdominal contents from pushing upward and inhibiting lung expansion.
This loosens secretions and facilitates the removal.
Helps clear secretions.
with whitish, tenacious secretions noted upon suctioning of the mouth and ET tube, approximately 20 cc
Patient was repositioned every two hours, made comfortable in bed while adjusting pillows; provided with chest physiotherapy upon change of position
Patient is monitored frequently; with slight elevation of the foot part to prevent sliding down the bed.
Patients VR set-up cmes with a humidifier; monitored frequently from getting used up
Patient is suctioned frequently for presence of secretions
Dependent Administer
medications (e.g. antibiotics-Levofloxacin, Vigocid; mucolytic agents, bronchodilators-Salbutamol) as ordered, noting effectiveness and side effects.
Collaborative Check and
monitor VR set-up and patient’s response.
These promote clearance of airway secretions and bronchodilation decreases airway resistance.
The basis for setting every parameter of the ventilator depends on the patient. Maintaining the correct settings for every parameter ensures the proper ventilation to the patient.
Patient was given ILN Salbutamol 1 nebule via face mask; with respiratory rate of 17-21 breaths per minute, regular, non-labored; with no side effects such as hypotension or bradycardia.
With ET tube at 21 cm attached to patient connected to a functional ventilator; with VR set-up of: tidal volume-450 ml, peak flow-50, back up rate-16 breaths per minute, FIO2-30%, and assist-control mode; weaned to T-piece at 40% and 8 liters of oxygen
Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0)
Subjective/Objective cues:
Nursing Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
Objective cues: GCS 5 –best
motor response is in decorticate position graded as 3
Unable to perform active range of motion exercises on all extremities
Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities, no joint motion)
Hand grasp of 0/3-none on both hands
Impaired physical mobility related to limitation in independent purposeful physical movement of the body secondary to motor never compression on frontal lobe
General:Within 2 weeks of medical and nursing interventions, client will be able to maintain or increase strength of the body and extremities.
Specific:Within 1 week of medical and nursing interventions, client will be able to:
Improve muscle strength on all extremities
Perform passive exercises on all extremities
Independent:Assessment:
Assess for developing thrombophlebitis (calf pain, Homan’s sign, redness, localized swelling, and hyperthermia)
Assess skin integrity
Therapeutic Keep side rails
up and bed in low position
Bed rest or immobility promotes clot formation
Regular examination of the skin especially on bony prominences will allow for prevention or early recognition and treatment of pressure sores.
This promotes a safe environment
Patient displays no signs of calf pain, redness and swelling on lower extremities, or hyperthermia.
Skin is dry, wrinkled, and rebounds instantly; with no signs of pressure sores or redness over bony prominences.
Patient is frequently monitored; secured raised side rails at all times; placed in low or semi-Fowler’s position
Turn patient every two hours
Maintain limbs in functional alignment
Perform passive ROM exercises on all extremities
Use pressure-relieving devices as indicated
Dependent: Administer
medications as ordered such as antispasmodic drugs (e.g. Vitamin B complex)
Turning position optimizes circulation to all tissues and relieves pressure.
Maintaining proper alignment pf extremities prevents contractures.
Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength.
This prevents tissue breakdown
Antispasmodic medications may reduce muscle spasms that interfere with mobility.
Patient is repositioned every 2 hours, massaged bony prominences, and placed pillows or rolled cloth for limbs and body support.
Patient was provided with pillows and properly rolled cloth to maintain alignment and support on all limbs.
Passive range of motion exercises was provided to patient on all extremities with proper support and execution.
Placement of pillows or rolled cloth to prevent pressure of skin contact to surface; gentle massage on bony prominences was provided
Vitamin B complex (Polynerv) 500 mg was given to patient
Collaborative: Set-up a bowel
program (e.g. adequate fluid, foods high in bulk, physical activity, stool softeners, laxatives) as needed. Record bowel activity level.
Prolonged bed rest, lack of exercise, and physical inactivity contribute to constipation. A variety of interventions will promote normal eliminations.
IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient, adjusted at a rate of 21 drops per minute; nutrition given through osteorized tube feeding of 1, 800 kcal in 6 equal feedings plus 6 egg whites; patient was also ordered with Lactulose 30 cc; no bowel movement noted since last week
Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0)
Subjective/Objective cues:
Nursing Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
Objective cues: presence of
surgical wound stitched across the right part of the head about 12 inches, vertical; with dry, intact 2 x 3 inches dressing
Risk for infection related to tissue destruction susceptible for invasion of pathogens.
General:Within 2 weeks of medical and nursing interventions, client will be able to prevent/reduce risk for infection.
Specific:Within 1 week of medical
Independent:Assessment:
Observe for localized signs of infection at surgical incision wound.
Note signs and symptoms of sepsis; fever,
To check for any signs of infection
To check for the presence of infection and give
Signs of infection were not noted; no visible signs of redness or pus around surgical site.
With normal temperature ranges from 35.6 C to 37. 1 C taken at left
on right parietal part of head
increased WBC (laboratory result of 14. 6 meq/L on January 7, 2013 )
Presence of an indwelling catheter and endotracheal tube
and nursing interventions, client will be able to manifest:
Absence of serosanguinous drainage from the surgical site.
Decrease or normal WBC value.
chills, diaphoresis.
Therapeutic: Change
surgical/wound dressings, as indicated, using aseptic technique for changing/ disposing of contaminated materials.
Health Teachings: Teach family how
to clean incision site daily and remind them to change dressings as needed.
Dependent: Administer or
monitor medication regimen (e.g. antibiiotics-Levofloxacin 750 mg, Vigocid 2.25 gm) and note patient’s response.
Collaborative: Note and report
laboratory values
necessary interventions.
To facilitate wound healing and prevent infection by minimizing growth and spread of microorganisms.
To educate the family about the right procedure to clean and change dressings.
To determine effectiveness of therapy.
To provide a global view of the patient’s immune function and nutritional status.
axilla; chills and diaphoresis not noted
Staff nurse on duty performed changing of surgical dressing, as indicated.
Significant other was instructed to follow correct hand washing and aseptic technique whenever in contact with a surgical wound.
Medications as directed follows the treatment duration for a certain number of days; completed the treatment regimen; temperature is within normal level of 35.6 C – 37 C;
Latest lab values for WBC was not checked by student nurses
Subjective/Objective cues:
Nursing Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
Objective cues:
Unable to pass stool since last week; with diet of osteorized tube feeding of 1, 800 kcal in 6 equal feeding plus 6 egg whites
Inactivity, GCS 5 –best motor response is in decorticate position graded as 3
muscle grade of 1/5 (muscle contraction on all extremities but no joint motion
Constipation related to inhibited defecation reflex secondary to compression of the pudendal nerve on the medial prefrontal lobe of the brain
General:
Within 3 weeks of medical and nursing interventions, client will be able to pass out soft, formed stool
Specific:
Within 1 day of medical and nursing interventions, client will be able to:
maintain normal bowel sounds within the range of 5-32 gurgling or clicking sounds
perform passive ROM exercises on all extremities
IndependentAssessment
assess usual pattern of elimination; compare with present pattern, include size, frequency, color, and quality
evaluate laxative use, type, and frequency
assess activity level
evaluate current medication usage that may contribute to
normal frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is “normal” for each individual
chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Over time, the colon becomes atonic and distended.
Prolonged bed rest, lack of exercise, and inactivity causes constipation
Drugs that can cause constipation include the
constipation
Therapeutic provide fluid
intake of 2000 to 3000 mL/day, if not contraindicated medically
provide passive ROM exercises on all extremities
Health Teachings reinforce to
caregiver the importance of the following:
a balanced diet consisting of
following: narcotics, antacids, antidepressants, anticholinergics, antihypertensive, general anesthetics, hypnotics, and iron and calcium supplements
Patients, especially older patients, may have cardiovascular limitations that require that less fluid be taken
Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitates defecation
These steps lead to reestablishing regular bowel habits
Twenty grams of fiber per day is
adequate fiber, fresh fruits, vegetables and grains
adequate fluid intake (2000-3000 mL/day)
regular exercise and activity
regular meals
Dependent
administer drugs such as Lactulose, as ordered
Collaborative
Health teachings teach use of
medications as ordered, as in the following:bulk fiber (Metamucil)
recommended
Increased hydration promotes softer fecal mass
Exercise strengthen abdominal muscles and stimulate peristalsis
Successful bowel training relies on routine
This laxative is characterized by a shorter colon transit time and accelerated bowel movement.
This increase fluid, gaseous,
stool softeners (Colace)
chemical irritants (castor oil, cascara, milk of magnesia)
suppositories
oil retention enema
and solid bulk of intestinal contents
Softens stool and lubricates intestinal mucosa
These irritate the bowel mucosa and cause rapid propulsion of contents and small intestine
Softens stool and stimulates rectal mucosa
Softens stool
Subjective/Objective cues:
Nursing Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
Objective cues:
GCS of 6 (best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)
Risk for Aspiration related to decreased level of consciousness secondary to cerebral hypoperfusion
General:
Within 1 week of medical and nursing intervention, patient’s risk will decrease as a result of ongoing assessment and early interventions
Specific:
Within 1 day of medical
Absent cough reflex
Presence of endotracheal, and nasogastric tubes attached to patient
and nursing interventions, patient will be able to:
Maintain a patent airway
Subjective/Objective cues:
Nursing Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
Objective cues: GCS of 6 (best
eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)
Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities, no joint motion)
Hand grasp of 0/3-none on both hands
Self-Care Deficit related to decreased level of consciousness secondary to cerebral hypoperfusion and compression of the motor nerve on the frontal lobe
General:
Within 3 weeks of medical and nursing interventions, patient will be able to safely perform (to maximum ability) self-care activities
Specific:
Within 1 day of medical and nursing interventions, patient will be able to:
Exhibit good hygiene and grooming