Institute of Nursing

NURSING CARE PLAN

Cues Nursing Analysis Goals/Objectives Intervention Rationale Evaluation

Diagnosis
SUBJECTIVE Ineffective Cerebral Edema Outcome: Did patient able to
The SO breathing  After 4 hours  Place patient  A sitting attained normal
verbalized that pattern r/t Increased ICP of nursing with proper position breathing pattern
“Binibigyan increase  intervention the body permits of 20 cpm?
siya ng intracranial Increased client: alignment for maximum YES?__
mannitol.” pressure as respiratory rate -Attain normal maximum lung NO?___
evidenced  breathing pattern breathing excursion and WHY?__________
OBJEVTIVE: by increased Ineffective of 20 cpm pattern. chest
 Dyspnea respiratory breathing pattern expansion.
 Nasal flaring rate
 Capillary Reference:  Encourage  This method Did patient able to
Pathophysiology diaphragmatic relaxes performs
refill (4
by Gold, 4th Short-term breathing for muscles and diaphragmatic
seconds) outcome: pursed-lip
edition p.345 patients with increases the
 Pale nail After 1 hour chronic patient’s breathing?
beds and of nursing disease. oxygen level. YES?__
conjunctiva intervention the NO?___
 O2Sat= 92% client:  Teach patient  These WHY?__________
 RR: 26 - Performs about: measures
diaphragmatic  pursed-lip allow patient Did patient able to
 BP=160/80
pursed-lip breathing to participate demonstrate stable
breathing  abdominal in vital signs and
breathing maintaining absence of signs of
- Demonstrate  performing health status increased ICP.?
stable vital signs relaxation and improve YES?__
and absence of techniques ventilation. NO?___
signs of increased  performing WHY?__________
ICP. relaxation
techniques
 taking
prescribed
 medications
(ensuring
accuracy of
dose and
frequency and
monitoring
adverse
effects)
 scheduling
activities to
avoid fatigue
and provide
for rest periods

 Given  Use is
Mannitol as controversial
doctors order in control of
cerebral
edema.

Reference:
Nursing care
Plan by
Marilyn
Doenges, 7th
edition
 Far Eastern University
Institute of Nursing
DRUG STUDY
Mechanism of Nursing
Name of Drug Indication Contraindication Side Effects Adverse Effects
Action Responsibilities
Generic Name: >Mild Decreases Contraindicated CNS: Hematologic:  Avoid using
paracetamol pain or fever by a in patients Anxiety, fatigue, Leukopenia, OTC drugs with
fever hypothalamic hypersensitive headache, neutropenia, Acetaminophen.
effect leading  Take with food
Brand Name: to drug I.V. insomnia, pyrexia. pancytopenia;
to sweating or milk to
Biogesic, and form is CV: anemia
Panadol, Tylenol contraindicated Hypertension, Metabolic: minimize GI
vasodilation
in patients with hypotension, Hypoglycemia, upset.
Inhibits
pyrogen severe hepatic peripheral edema, hypokalemia,  Report N&V.
Therapeutic effect on the cyanosis,
impairment or periorbital edema, hypomagnesemia
Class: hypothalamic- shortness of
severe active tachycardia (I.V.) Respiratory:
Analgesics heat- breath and
liver disease. GI: Hypoxia, abdominal pain
regulating
centers Use cautiously Nausea, vomiting, pulmonary as these are
Pharmacologic in patients with abdominal pain, edema, stridor
Inhibits CNS signs of
Class: any type of liver diarrhea,
prostaglandin toxicity.
Para-
synthesis with disease, chronic constipation(I.V.)  Report
aminophenol malnutrition, GU: paleness,
minimal
derivatives severe Oliguria weakness and
effects on
peripheral hypovolemia, or Hematologic: heart beat skips
Route of
prostaglandin severe renal Hemolytic anemia  Report
Administration: impairment Metabolic: abdominal pain,
synthesis
TIV Hypervolemia, jaundice, dark
hypophosphatemia urine, itchiness
Dosage: or clay-colored
Respiratory:
180 mg stools.
Abnormal
 Phenmacetin
breathing sounds,
may cause urine
dyspnea, to become dark
wheezing brown or wine-
colored.
Skin:  Report pain that
Rash, infusion-site persists for
pain more than 3-5
days
 Avoid alcohol.
 This drug is not
for regular use
with any form
of liver disease
 Far Eastern University
Institute of Nursing
DRUG STUDY
Name of Drug Indication Mechanism Contraindication Side Effect Adverse Reactions Nursing
of Action Responsibilities
Generic To promote In large Anuria; marked Pulmonary CNS: Headache, Assessment &
Name: diuresis in doses, pulmonary congestion, tremor, convulsions, Drug Effects
Mannitol prevention and increases congestion or fluid and dizziness, transient
treatment of rate of edema; severe CHF; electrolyte muscle rigidity. CV: Take care to
Brand Name: oliguric phase of electrolyte metabolic edema; imbalance, Edema, CHF, avoid
Osmitrol acute kidney excretion by organic CNS acidosis, angina-like pain, extravasation.
failure. Also the kidney, disease, intracranial electrolyte hypotension, Observe injection
Classification: used to reduce particularly bleeding; shock, loss, dryness hypertension, site for signs of
Electrolyte and elevated sodium, severe dehydration, of mouth, thrombophlebitis. inflammation or
water balance intraocular (IOP) chloride, and history of allergy; thirst, Eye: Blurred vision. edema.
agent, Osmotic and intracranial potassium. pregnancy (category marked GI: Dry mouth,
Diuretic pressure (ICP), C), lactation; diuresis, nausea, vomiting. Lab tests:
to relieve concomitantly with urinary Urogenital: Marked Monitor closely
Dosage: symptoms of blood. retention, diuresis, urinary serum and urine
100 ml pulmonary edema, retention, nephrosis, electrolytes and
edema. headache, uricosuria. kidney function
Route: Commercially blurred Metabolic: Fluid during therapy.
Intravenous available in vision and electrolyte
combination imbalance, Measure I&O
with sorbitol for especially accurately and
urogenital hyponatremia; record to achieve
irrigation. dehydration, proper fluid
acidosis. Other: balance.
With extravasation
(local edema, skin Monitor vital
necrosis; chills, signs closely.
fever, allergic Report significant
reactions). changes in BP
and signs of
CHF.

Monitor for
possible
indications of
fluid and
electrolyte
imbalance (e.g.,
thirst, muscle
cramps or
weakness,
paresthesias, and
signs of CHF).

Be alert to the
possibility that a
rebound increase
in ICP sometimes
occurs about 12 h
after drug
administration.
Patient may
complain of
headache or
confusion.

Take accurate
daily weight.