NURSING CARE PLAN

ACTUAL
PROBLEM SCIENTIFIC NURSING PLAN/GOAL INTERVENTION RATIONALE EVALUATION
CUES BASIS DIAGNOSIS

S/O: Respiratory Ineffective Within our 8 1. Frequently  To Goal met;

 gasping depression is breathing hours span of assess the maintain as
and reduced pattern related nursing care patient’s and evidenced
shortnes function of the to our patient will respiratory support by absence
s of brainstem neuromuscular be able to; status, vital of cyanosis
breath neurons that dysfunction vital signs, functions. and other
noted trigger secondary to a. Establish a heart rate signs and
 with RR breathing CVA normal and symptoms
of 30 movements. effective rhythm. of hypoxia

 nasal Neurons can respiratory 2. Note  Because and a

flaring be damaged or pattern emotional hyperven normal

noted destroyed by b. Be free of responses tilation respiratory

 with trauma or cyanosis for may be a rate of 22

Oxygen when problems and other example factor. beats per

inhalatio in other areas signs and gasping, minute.

n of of the brain symptoms crying,

5L/hour increase the of hypoxia tingling

ICP. Such an finger.
increase 3. Assess for  It may
causes edema, concomita restrict or
which leads to nt pain limit
pressure on and respirator
the respiratory discomfort y effort.
centers located
in the brain
stem.
{ Ignatavicius,
Donna D. et al;
Medical
Surgical
Nursing:5th
edition; Copy
right 2006} 4. Elevate  To
head of promote
bed as physiolog
appropriat ic ease of
e. Patient maximal
on MHBR inspiratio
as ns. Helps
ordered. decrease
 d ICP.

5. Encourage
slower &  To assist
deeper client in
respiration “taking
s, use of control”
pursed- lip of the
technique. situation.
6. Administer
oxygen as  To
ordered. maximize
cerebral
oxygenati
on.
 PROBLEM SCIENTIFIC NURSING PLAN/GOAL INTERVENTION RATIONALE
CUES BASIS DIAGNOSIS

S/O; The motor Impaired Within our 8 hours span 1. Review  Identifies
 Body examination physical mobility of nursing care our functional probable
malaise provides related to patient will be able to; ability and functional
noted information neuromuscular reasons for impairment
 With about which part impairment a. Demonstrate impairment and
limited of the brain is secondary to techniques and influences
range of involved. A right CVA behaviors that 2. Provide and choice of
motion hemiplegia enable assist with interventions.
 With indicates a resumption of ROM  Maintains
decrease stroke involving activities. exercise. mobility and
muscle left cerebral b. Maintain skin function of
strength hemisphere integrity. 3. Position joints/
at the left because the client to functional
side motor nerve avoid skin alignment of
fiber across in and tissue extremities
the medulla pressure. and reduces
before entering Turn at venous
the spinal cord regular stasis.
and periphery. intervals, and  Regular
make small turning more
{ Ignatavicius, position normally
Donna D. et. al; changes distributes
Medical Surgical between body weight
th
Nursing:5 turns. and promotes
edition:Copy circulation to
right 2006 } 4. Remove wet all areas.
linen and
clothing,  Promotes
keep circulation
bedding free and skin
of wrinkles. elasticity and
reduces risk
of skin
excoriation.
 Reduces risk
of
constipation
related to
decreased
level of
activity.
5. Encourage
diet high in
 fiber and
adequate
fluid intake.

PROBLEM SCIENTIFIC NURSING PLAN/GOAL INTERVENTION RATIONALE EVALUATION

 CUES BASIS DIAGNOSIS

S/O: As the patient’s High risk for Within my 8 1. Evaluate client’s  Evaluate Goal met:;
state of falls related to hours span of cognitive status. client’s As
 Irritabilit alertness and diminished nursing care cognitive evidenced
y noted consciousness mental status my patient will status. by patient’s
decreases, secondary to be able to be integrity still
 with there will be CVA. free from injury 2. Provide needed intact and
restraint changes in the or any interventions and absence of
s papillary activities that safety  Provide injury to any
on both hands response eye will contribute measures/device needed part of the
opening to falls and s such as placing intervention body.

 Restlessn response, injury. pillows at bedside s and

ess verbal and and raising side safety
noted motor rails. measures/
response. devices
 with NVS Initial changes such as
GCS may be placing
of 12 reflected by pillows at
subtle 3. Decrease bedside
behavioral extraneous and raising
changes such stimuli and side rails.
as restlessness provide comfort
or increased measures {e.g.  Decrease
anxiety. quiet extraneous
{Smeltzer, environment, stimuli and
Suzamme C. et speaking in a soft provide
al; Medical voice, gentle comfort
Surgical touch as measures
Nursing:10th tolerated}. {e.g. quiet
edition, environme
lippincott nt,
Williams and speaking in
Wilkins; Copy a soft
right 2004} voice,
4. Investigate gentle
increase touch as
restlessness. tolerated}.

 Investigate
5. Administer anti increase
seizure restlessnes
medications as s
ordered/indicated
 Administer
anti seizure
medication
s as
ordered/
indicated
WELLNESS
PROBLEM SCIENTIFIC NURSING PLAN/GOAL INTERVENTION RATIONALE EVALUATION
CUES BASIS DIAGNOSIS

S/O; As the patient’s Ineffective Within our 8 1. Determine It Goal met:;
 Irritability state of tissue perfusion hours span of factors related influences As
noted alertness and related to nursing care to decrease choice of evidenced
 Restlessn consciousness interruption of our patient will; cerebral interventions. by patient’s
ess noted decreases, blood flow; perfusion Deterioration integrity still

 With NVS there will be hemorrhage a. Display no in intact and

GCS of 12 changes in the secondary to further 2. Position with neurological absence of

 Decrease papillary CVA deterioratio head slightly sign and injury to any

muscle response eye n elevated and symptoms or part of the

strength opening b. Maintain neutral position failure to body.

response, usual/ improve after
verbal and improved initial insult
motor level of 3. Maintain bed may reflect
response. consciousn rest, provide decrease
Initial changes ess, and quiet intracranial
may be motor environment. adaptive
reflected by function Provide rest capacity.
subtle periods  Reduces
behavioral between care arterial
changes such activities. pressure by
as restlessness promoting
or increased venous
anxiety. 4. Administer drainage and
{Smeltzer, supplemental may improve
Suzamme C. et oxygen as cerebral
al; Medical ordered. circulation.
Surgical Continual
th
Nursing:10 stimulation
edition, 5. Monitor blood can increase
lippincott pressure, ICP.
Williams and compare Absolute rest
Wilkins; Copy readings. and quiet
right 2004} may be
needed to
prevent
rebleeding in
the case of
hemorrhage.
Reduces
hypoxemia,
which can
cause
cerebral
vasodilation
and increase
pressure.
Fluctuation
s in pressure
may occur
because
cerebral
pressure in
vasomotor
area of the
brain.