NURSING CARE PLAN Name of Patient: Mr. X Attending Physician: Dr.

Asoy Cc: Lacerated wound Age/Sex: 55/M

CUES Subjective: Nakilala ka ha akon? asked by the wife to the patient. Objective: Inability of the patient to recognize his wife and other persons that surrounds him.

NURSING DIAGNOSIS Impaired memory related to traumatic event evidence by inability to recognize patients wife

SCIENTIFIC RATIONALE Head injury and injury to the brain specifically at the cerebral cortex which is responsible for memory storage is associated with trauma, with great majority resulting from automobile crashes. When forces exceeds absorption capacity is transmitted to the brain and tissue damage result. This traumatic head injury usually correlates with the amount of force

OBJECTIVES After 3 days of nursing intervention, the patient will be able to: 1. Improve usual reality orientation by: - reorientation of his ADLs with the help of S.O 2. Establish methods in remembering things when possible with the S.O by: - providing things that were

IMPLEMENTATION Independent: Allow adequate time for client to respond to questions/com ments and to make decisions. Discuss happenings of the past.

RATIONALE

EVALUATION

- Reaction time may be slowed with aging or brain injuries.

- To become more readily recalled by the client, because long term memory usually remains intact. Reminiscence/ life review are beneficial to the client.

applied to the cranial contents. Typically the patient experience a brief immediate loss of consciousness associated with left parietal head fracture reveal motor- sensory dysfunction. Source: Pathophysiology by: Barbara Bullock and Reet Henze Page 946-947

significant to the patient.

Reorient to person/place and time as appropriate. Have client repeat verbal/written instructions Involve in regular exercise, activity and diversional programs. Schedule at least one rest per day.

- help client maintain focus.

- Verifies hearing/ ability to read and comprehend. - Promotes release of endorphins, enhancing sense of well-being, and improve thinking abilities.

-Prevents fatigue; enhances general well-being.

Maintain quiet, calm environment. Encourage ventilation of feelings of frustration,

- To lessen anxiety.

- To lessen feelings of powerlessness/hopelessness.

helplessness. Monitor clients behavior and assist in use of stressmanagement techniques. Collaborative: Review results of laboratory/dia gnostic test such as CT Scan. Refer to/encourage follow-up with counselors, rehabilitation programs, job coaches, social/financia l support system. Establish baseline data. To reduce frustration.

- To help deal with persistent/difficult problems.