NURSING CARE MANAGEMENT

Ineffective Cerebral Tissue Perfusion

related to Narrowing and Occlusion of Cerebral Artery

Subjective Cues: “mura gyapon siyag gakalipong, mo storya siya

na dili masabatan pero murag ingon niya na lipong daw ” as verbalized by the watcher

Objective Cues:

• BP = 180/80mmHg• Drowsiness noted• Decreased level of consciousness• Left-Sided Body Weakness noted• Uneasiness noted

GOALS AND OBJECTIVES

SHORT TERM:• Within 2-3 hours of nursing intervention,• Client will demonstrate adequate tissue perfusion

AEB blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses, and ability to tolerate activity without dyspnea, syncope or chest pain

Long term:• Within 2-3 days of nursing intervention,• Client will verbalize knowledge of their treatment

regimen, including appropriate exercise and medications, their actions and possible side effects

NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT: • Monitor vitals signs such as Respi Rate, Pulse Rate

and Blood Pressure• Promote rest periods with body flat on bed and turn

to sides every two hours • Provide safety such as lowering level of bed, putting

pillows on the side of the patient, or assisting person on bed mobility

• Encourage patient to avoid stressful situation

DEPENDENT:• Administer Anti-hypertensive drugs such as Captopril

COLLABORATIVE • 1. REPORT TO HEALTH CARE TEAM OF ANY

ABNORMALITIES

Activity Intolerance

related to Loss of Muscle strength

Subjective Cues: “dili siya makalihok pag siya ra isa” as verbalized

by the watcher......

Objective Cues: • Impaired ability to turn to sides, move from supine

to sitting position and to reposition self in bed noted• Weakness noted

• Vital signs• = 170/100• = 28cpm• =110bpm Functional level classification = 2 (requires help from another person)

GOALS AND OBJECTIVES

Short term• Achieve improved activity tolerance in

terms of turning to sides, and of changing positions

• Maintain position that allows improved function and skin integrity as evidenced by absence of contractures, decubitus ulcers and so forth  

• Long term • Demonstrate behaviors/techniques that

enable completion of Activities of Daily Living such as toileting, eating, grooming, bathing and etc.

NURSING INTERVENTIONS AND RATIONALE

Independent• Evaluate client’s actual and perceived

limitation /degree of deficit in light usual status.

• Turn dependent client frequently (every 2 hours), utilizing bed and mattress positioning settings to assist movements, reposition in good body alignment, using appropriate support

• Instruct client and caregivers aim for positions which is most comfortable to client

• Observe skin for reddened areas/shearing. Provide appropriate pressure relief to reduce friction, maintain safe skin and wick away moisture

• Instructed SO’S to limit the activities/exertion of the client

• Assist in learning and demonstrating appropriate safety measures

• Encourage to have early ambulation• Encourage to maintain positive attitude;

suggest use of relaxation techniques. Such as visualization/guided imagery and deep breathing exercise

• Explain to the client the importance od Range of motion exercises.

• Assist patient in doing Passive Range of Motion.

 Collaborative• Include physical therapist in creating

movement program, and Range of Motion Exercises when indicated with bed rest

Risk for impaired skin integrity related to decrease activity to move

 

Risk Factors:

• body weakness(left sided)• Limited movement

• slightly decreased ROM

GOALS AND OBJECTIVES

Short term:• Patient and significant (SO’s) identify the

risk factors• Patient and significant others (SO’s)

verbalize understanding of the importance of treatment/ therapy regimen.

• Maintain position that allows improved function and skin integrity as evidenced by absence of contractures, decubitus ulcers and so forth

 Long term: • •Demonstrate behaviors/techniques to

prevent skin breakdown

NURSING INTERVENTIONS and RATIONALE

Independent:• Assess skin routinely, noting moisture,

color, and elasticity.• Observed for reddened/blanched areas of

skin • Instruct SO’S the need/importance of

massaging the bony prominences and the use of proper positioning, turning, lifting and transferring when moving client

• Instruct and demonstrate change position in bed/chair on a regular schedule and encourage early ambulation, active and assistive range-of-motion

• Instructed the importance of adequate clothing/covers; protect from drafts

• Keep bedclothes dry and wrinkle free, use nonirritating linens and provide protection by use of pillows

• Instructed SO’S to change diapers frequently; cleanse perineal skin daily and after incontinence episode

• Emphasize importance of adequate nutritional/fluid intake

• Keeping the nails short

Collaborative: • Refer to dietitian as appropriate as the

finances availability

EVALUATION

Goals met• At the end of 8 hours nursing management

patient was able to:• patient and SO’S identified the risk factors

that could contribute to skin breakdown • SO’S verbalized understanding regarding

the need of treatment to prevent from any additional complication

•Patient maintained position that allow her improved her comfort and skin integrity

•Demonstrate behaviors in preventing skin breakdown

Risk of Injury related to Decreased ability to move secondary to

Left-Sided Body Weakness

Risk factors:

• decreased LOC• left sided weakness noted• altered thought processes• Extremes of Age : 71 years

old

GOALS AND OBJECTIVES

• Understanding of risk factors that contribute to possibility of injury,

• Demonstrate behaviors, lifestyle changes to reduce and protect from injury as well as to be free from injury.

NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT• Assess the person for factors known to

increase injury risk such as history of falls, mental status changes and sensory deficits.

• Assess patient’s environment for factors known to increase fall risk such as unfamiliar setting and inadequate lighting.

• Perform thorough assessments regarding safety issues when planning for client care

• Place items used by the patient within easy reach and maintain bed/chair in lowest position with wheels locked.

• Keep the side rails of the raised.

• Frequent skin inspections.• Encourage the patient to

participate in a program of regular exercise

COLLABORATIVE Refer the person for diagnostic

musculoskeletal evaluation.• Refer the family to community

resources for assistance in making home safety modifications

EVALUATION

GOALS MET. At the end of 8 hours of nursing

intervention, Patient was able to:• verbalized understanding on risk factors

that may contribute to possibility of injury,

• demonstrated behaviors to be free from injury and that safety is ensured.

Altered Nutrition: Less than body requirements

related to Altered Ability to Swallow

SUBJECTIVE CUES:• “Dili kayo siya maka tulon ug maayo mauna

gamay ra iyang gaka kaon” as verbalized by the watcher

OBJECTIVE CUES:• Body weight of 56 kg.• Weakness of muscles (i.e. tongue muscles)

required for swallowing or mastication• Dry and pale mucous membranes• Brittle Hair• Lab results:• Decreased albumin: • Electrolyt///e imbalance:• Na+:

GOALS & OBJECTIVES

Short Term• Verbalize understanding of causative

factors when known & necessary interventions

• Demonstrate behaviors, to regain appropriate weight, by consuming at least ½ to ¾ of food serving

Long Term • Demonstrate progressive weight gain of at

least 2 lbs. from previous weight

NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT:•Determine the patient’s ability to chew, swallow & taste food.•Weigh as indicated. Evaluate weight in terms of premorbid weight. Compare serial weights & anthropometric measurements.•Encourage client to choose foods or have family members bring foods that seem appealing .•Advise patient to limit consumption of bulk/fiber foods.•Promote timely fluid intake.•Encourage the use of lozenges and so forth.

DEPENDENT:• Administer pharmaceutical

agents like appetite stimulants as indicated.

• Administer vitamin/mineral (iron) supplements including chewable multivitamin medications as indicated.

COLLABORATIVE:• Consult dietitian or nutritional

team, as indicated.

EVALUATION

Goals Met.

After 8 hours of duty, my patient was able to:

• Verbalize understanding of causative factors when known & necessary interventions

• Demonstrate behaviors, to regain appropriate weight, by consuming at least ½ to ¾ of food serving.

After 2 weeks of duty, my patient was able to:

• Gain 2 lbs. after admission.

Hyperthermia related to Compromised Cerebellar Thermoregulatory Function

secondary to Middle Cerebral Artery Infarction

Subjective:• “Ma’am, nikalit lang siya’g init karong

hapon” as verbalized by the watcher.

Objective: • Temperature: 38.3˚C• Skin Warm to touch• Dry Skin Noted• Warm Breath noted

GOALS & OBJECTIVES

After 20 mins of nursing interventions:

• Patient’s temperature from 38.3˚C→37.5˚C

• The patient will be free from any complications due to Hyperthermia

NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT:• Explain to the client the importance

of Tepid sponge Bath.• Perform Tepid sponge Bath • Do mouth Care CarefullyDEPENDENT:• Administer PARACETAMOL 500mg.• R: to help lower patient’s

temperature.

EVALUATION

Goals met as evidenced by :• Temperature 37.5˚C• (―) dry skin• (―) Warm breath

Deficient Knowledge

related to Unfamiliarity with regards to condition and treatment regimen

Subjective Cue:• “Unsa diay ni ako sakit day? Unsay

rason? Unsa amo buhaton?” as verbalized by the patient

 Objective Cues:• Educational Status- undergraduate of

Elementary; only until fifth grade

GOALS AND OBJECTIVES

Short Term:

After 2 hours of Nursing Intervention the patient will be able to:

• Participate in learning process• Identify interferences to learning and

specific action to deal with them.• Verbalized understanding of

condition or disease process and treatment.

• Initiate necessary lifestyle changes and participate in treatment regimen.

NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT: • Ascertain level of knowledge,

including ancipatory needs• Discuss client’s perception o need.

Relate information to client’s personal desires or needs and values or beliefs.

• Identify information that needs to be remembered

• Determine client’s method of accessing information to facilitate learning.

• Provide mutual goal setting and learning contracts.

• Begin with information the client already knows and move to what the client does not know, progressing from simple to complex. Limit sense of being overwhelmed.

• Deal with the client’s anxiety. Present information out of sequence, If necessary, dealing first with material that is most anxiety-producing when anxiety is interfering with the client’s learning process.

• Be aware of informal teaching and role modeling that takes place on an ongoing basis.

• Assist client to use information in all applicable areas.

EVALUATION

Goal’s Met.

After 2 hours of nursing intervention, the patient was able to participate the learning process and able to understand the condition or disease process and treatment.