Nursing Care Plan

ASSESSMENT SCIENTIFIC

EXPLANATION

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

”Hindi ko maigalaw

ang aking kaliwang

kamay at medyo

hindi ko rin

maigalaw ang kaliwa

kong paa.”

Objective:

Left hemi paralysis

Limited range of

motion (ROM)

Functional level:

level 2-requires help

Impaired physical

mobility related to

neuromuscular

impairment

Neuromuscular

disorders affect the

nerves that control

the voluntary

muscles. Voluntary

muscles are the

ones that can be

controlled, like in the

arms and legs. The

nerve cells, also

called neurons,

send the messages

that control these

muscles. When the

neurons become

unhealthy or die,

communication

between the

Short term

After 4 hours, the

patient verbalize

understanding

situation or risk

factors and

individual treatment

regimen and safety

measures

Long term

After 4 months of

continuous ,effectiv

e and collaborative

nursing

interventions,

Monitor V/S

Determine the

diagnosis that

contributes to

immobility

Encourage and

facilitate early

ambulation and

other ADLs when

possible. Assist with

each initial change:

dangling, sitting in

chair, ambulation

To note changes

and for baseline

comparison.

To be informed

about the

situations that

may restrict

movements

The longer the

patient remains

immobile the

greater the level

of debilitation that

will occur

After 4 hours of

nursing intervention

the patient was able

to verbalize

understanding

situation or risk

factors and

individual treatment

regimen and safety

measures

After 4 months of

continuous ,effective

and collaborative

nursing

interventions,

patient was able to

maintain position

from another person. nervous system and

muscles breaks

down. As a result,

the muscles weaken

and waste away.

The weakness can

lead to twitching,

cramps, aches and

pains, and joint and

movement

problems.

Sometimes it also

affects heart

function and ability

to breathe. Many

neuromuscular

diseases are

genetic, which

means they run in

families or there is a

mutation in your

patient will

maintain position,

function and skin

integrity

Perform passive or

active ROM

exercises to all

extremities

Turn and position

every 2 hours or as

needed.

Provide safety

measures(side rails,

using pillow to

support body part)

Massage back and

Exercise

promotes

increased venous

return, prevents

stiffness, and

maintains muscle

strength and

endurance

This optimizes

circulation to all

tissues and

relieves pressure.

To provide safety

and reduce the

risk of pressure

ulcers

and function and

skin integrity as

evidenced by the

absence of

contractures,

footdrop, decubitus

and so forth

genes. Sometimes,

an immune system

disorder can cause

them. Most of them

have no cure. The

goal of treatment is

to improve

symptoms, increase

mobility and

lengthen life.

bony prominences

Consult with

physical or

occupational

therapist as

indicated

It provides comfort

to the patient and

promotes good

circulation

To develop

individual exercise

therapy or

program

Reference:

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=35

ASSESSMENT SCIENTIFIC

EXPLANATION

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“Hindi ako

mapadumi.”

Objective:

Abdominal pain,

urgency

Altered bowel

sounds

Left Hemi paralysis

Limited ROM

Constipated for five

days

Constipation related

to insufficient

physical activity

A decrease in a

person's normal

frequency of

defecation,

accompanied by

difficult or

incomplete passage

of stool and/or

passage of

excessively hard,

dry stool. A lack of

physical activity can

lead to constipation.

For example,

constipation often

occurs after an

accident or during

an illness when one

must stay in bed

and cannot

exercise. Lack of

After 8 hours, the

patient will establish

or return to normal

patterns of bowel

functioning

Determine stool

color, consistency,

frequency and

amount

Auscultate

bowel sounds

Encourage

increased fluid

intake, 2500-3000

ml/day within

cardiac tolerance

Encourage to

eat high-fiber rich

foods

Assist in

identifying

causative and

contributing

factors and

appropriate

interventions

Bowel sounds are

generally

decreased in

constipation

Assists in

improving stool

consistency

To enhance easy

defecation

After 8 hours, the

patient was able to

establish or return to

normal patterns of

bowel functioning as

evidenced by easy

passage of

long, round, and

smooth brown-

shaded stool with a

texture similar to

creamy peanut

butter

physical activity is

thought to be one of

the reasons

constipation is more

common in older

people.  Moreover,

increased physical

activity is more

likely to stimulate

bowel motility and

improve the

symptoms of

constipation.

Recommend

avoiding gas-

forming foods

Assist in

perianal skin

condition frequently,

noting changes or

beginning

breakdown

Discuss use of

stool softeners, mild

stimulants, bulk-

forming laxatives, or

enemas as

indicated. Monitor

effectiveness

Decrease gastric

distress and

abdominal

distention

Prevents skin

excoriation and

breakdown

Facilitates

defecation when

constipation is

present

Identify factors

(e.g., medications,

bed rest, diet) that

may cause or

contribute to

constipation.

Evaluate medication

profile for

gastrointestinal side

effects.

Consult

dietitian to provide

well-balanced diet

high in fiber and

bulk

Constipation is a

common side

effect of many

drugs including

narcotics and

antacids.

Fiber absorbs

water, which adds

bulk and softness

to the stool and

speeds up

passage through

the intestines

Reference:

http://www.med.umich.edu/1libr/aha/umconstipation.htm

ASSESSMENT DIAGNOSIS SCIENTIFIC

EXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

“ayoko kumain ng

walang lasa”

OBJECTIVE:

>pale to pinkish

conjunctiva and lips

>weak looking

>fair appetite,

selective with food

Impaired adjustment

related to health

status requiring

change in lifestyle

Inability to modify

lifestyle in a manner

consistent with a

change in status.

The objective of

nursing care for

hypertensive

patients focuses on

lowering and

controlling the blood

pressure without

adverse effects and

Short Term Goal

After 4 days of

nursing intervention,

there will be an

increase interest and

participation on the

demonstration of self

care and will initiate

lifestyle changes that

will permit

adaptation to

present medical

Independent

Vital signs

monitored and

recorded. BP

monitored regularly

Assist the patient

in identifying

modifiable risk

factors like diet

high in sodium,

saturated fats and

For baseline

comparison

These risk factors

have been shown

to contribute to

hypertension

After 4 days of

nursing interventions

the goal is met

through participation

and demonstration

of lifestyle changes

preferences

BP-130/90 mmHg

without undue cost.

To achieve these

goals, the nurse

must support and

teach the patient to

adhere to the

treatment regimen

by implementing

necessary lifestyle

changes like

avoidance of foods

high in sodium and

fats and taking

medications as

prescribed.

situation cholesterol

Instruct and

emphasize

necessary care

and lifestyle

changes that will

enhance her

recovery.

Plan necessary

care and

assistance in ADLs

with the relative

Emphasize the

importance of

adequate rest

Emphasize the

This will promote

trust and will on

the patient to

adhere to such

activities that will

enhance fast

recover

Planning with the

relative will add

more cooperation

of the patient

This will lower the

patient’s BP

Hypertension

needs medications

importance of

adherence to

medications

Provide an open

environment

encouraging

communication

to maintain the BP

in its normal range

Expression of

feelings

concerning

impaired function

is dealt with

realistically

Reference:

http://www.medicinenet.com/high_blood_pressure/article.htm

DRUG STUDY

Name of Drug Classification Indications Side Effects Contraindications

Nursing

Responsibilities

Monitoring

Parameters

Generic Name:

Mannitol

Brand Name:

Osmofudin 20%

Route and

Frequency:

IV q4

Dose:

100 cc

Miscellaneous Fluids

or Diuretics

Action

-increase osmotic

pressure of

glomerular filtrate

which inhibits tubular

re-absorption of

water and

electrolytes and

increases urinary

output

Reduction of

increased

intracranial

pressure

associated with

cerebral edema

Reduction of

increased ocular

pressure

Promotion of

diuresis in the

prevention and/or

treatment for

oliguria or anuria

due to acute

renal failure

Dizziness

Headache

Convulsions

Blurred vision

Diuresis

Dry mouth

Loss of hearing

Hypersensitivity

Severe renal

disease

Severe

dehydration

Pulmonary

congestion

Assess patient’s

condition before

therapy and

regularly

thereafter to

monitor drug

effectiveness

Assess for

possible drug

induced adverse

reactions.

Assess patient

for possible drug

induced adverse

reactions.

Teach patient to

recognize and

immediately

report adverse

Monitor vital

signs, CVP, and

urine specific

gravity

Monitor

manifestations of

electrolyte

imbalance

Assess BP

before and during

the therapy with

patient lying,

standing and

sitting, orthostatic

hypotension can

occur rapidly.

reactions

Asses patient’s

and family’s

knowledge of

drug therapy

Name of Drug Classification Indications Side Effects Contraindications

Nursing

Responsibilities

Monitoring

Parameters

Generic Name:

Citicholine

Brand Name:

Cytidine

Diphosphate Choline

Route and

Frequency:

IV q12

Dose:

CNS stimulants or

Neurotonics

Action

-A derivative of

choline and cytidine

involved in the

biosynthesis of

lecithin. It is claimed

to increased blood

flow and oxygen

consumption.

CVA in acute and

recovery phase.

Signs and

symptoms of

cerebral

insufficiency.

Recent cranial

trauma

Parkinson’s

disease

Shock

Hypersensitivity

Hypotension

Insomnia

Stimulates

parasympathetic

action and

fleeting and

discreet

hypotension

effect

Hypertonia of the

parasympathetic

nervous system

Pregnancy and

lactation

Evaluate patient

medical history

Assess patient

condition

Should not be

administered to

patient with

hypertonia of the

parasympathetic

nervous system

Caution that

large doses could

Monitor vital

signs

Assess allergic

reaction like GI

disturbances

1 gm aggravate

increase in

cerebral blood

flow in episodes

of persistent

intracranial

hemorrhage.

Teach patient to

gain benefits and

not to miss any

dose

Name of Drug Classification Indications Side Effects Contraindications

Nursing

Responsibilities

Monitoring

Parameters

Generic Name:

Simvastatin

Cardiovascular

Statins

To reduce LDL

cholesterol,

Abdominal pain

Constipation

Hypersensitivity

to any

Assess nutrition:

fat , protein,

Monitor

creatinine

Brand Name:

Altovast

Route and

Frequency:

Oral Od

Dose:

40 mg

Action

-Inhibits HMG-COA

reductase enzyme,

which reduces

cholesterol

production

apolipoprotein

beta and

triglycerides

To increase HDL

cholesterol in the

treatment of

hyperlipidaemias

Coronary heart

disease

Flatulence

Insomnia

Headache

Rashes

Dizziness

Muscle cramps

component of the

preparations

Children and

lactation

Active liver

disease

Unexplained

persistent

elevations of

serum

transaminases

carbohydrates;

nutritional

analysis should

be completed by

dietitian before

treatment is

initiated

Assess liver

function tests

prior to therapy

and periodically

thereafter

Evaluate

therapeutic

response and

adverse

reactions on a

regular basis

Assess

knowledge or

teach patient

phophokinase

levels due to

possibility of

myopathy; serum

cholesterol

Monitor

triglycerides,

cholesterol

baseline and

throughout

treatment

proper use

Name of Drug Classification Indications Side Effects Contraindications

Nursing

Responsibilities

Monitoring

Parameters

Generic Name:

Imidapril

Brand Name:

Vascor

Route and

Frequency:

Oral OD

Dose:

50 mg

Cardiovascular

drugs

“antihypertensive”

Action

-inhibits angiotensin

converting enzyme;

reduction of

angiotensin II

resulting in dilation

of peripheral vessels

and reduction of

vascular resistance

Treatment of

hypertension

Dry cough

Headache

Rash

Palpitation

Fatigue

Discomfort in the

throat

Patients with

known

hypersensitivity

to angiotensin

converting

enzyme inhibitors

or with history of

angioneorotic

edema

Pregnancy and

lactation

Establish

baselines in

renal, liver

function tests

before therapy

Check for edema

Asses for patient

allergic reactions

Advise patient to

avoid potassium,

salt substitutes

Teach patient

how to take Bp

and normal

readings for age

Monitor blood

studies

Monitor bp,

orthostatic

hypotension

Monitor

electrolytes

during the firs 2

weeks of therapy

Monitor renal

studies and

symptoms

group

Name of Drug Classification Indications Side Effects Contraindications

Nursing

Responsibilities

Monitoring

Parameters

Generic Name:

Clonidine

Brand Name:

Catapres

Route and

Frequency:

Oral OD

Dose:

75 mcg

Cardiovascular drugs

“Centrally-acting

drugs”

Action

-stimulates central-

alpha adrenergic

receptors to inhibit

sympathetic

cardioaccelareators

and vasoconstrictor

centers

Management of

all grades of

hypertension with

the exception of

HPN due to

phaeochromooyto

ma

Prophylactic

treatment of

migraine or

recurrent

vascular

treatment of

migraine

For relief of

Local skin

irritation

Drowsiness

Dry mouth

Headache

Fatigue

Anorexia

Anxiety

Hypersensitivity to

clonidine

Sick sinus

syndrome

Assess pain,

location, intensity,

character,

alleviating,

aggravation

factors, baseline

and frequency

Perform blood

studies,

neorophils,

decreased

platelets

Perform renal

studies

Assess Bp and

apical pulse

Monitor baselines

for renal, liver

function test

before therapy

begins

Monitor BP,

standing, sitting,

supine, mental

status, and heart

rate.

cancer pain before initial dose

Note allergic

reactions

NAME OF DRUG CLASSIFICATION INDICATIONS SIDE EFFECTS CONTRAINDICATIONS NURSING

RESPONSIBILITIES

MONITORING

PARAMETERS

Generic Name:

Ranitidine

Brand Name:

Zantac

Route:

I.V

Frequency:

q 12

Dose:

50 mg

Gastrointestinal /

hepatobiliray Drugs”

H2 Receptor

Antagonists”

Mechanism of

Action:

Inhibits histamine

at H2 receptor site

in the gastric

parietal cells, which

inhibits gastric acid

secretion.

Used in

management of

gastrointestinal

(GI) disorders.

Prophylaxis of

GI hemorrhage

from stress

ulceration and in

patients at risk

of developing

acid aspiration

during general

anesthesia.

Bradycardia

Headache

Fatigue

Depression

Rashes

Constipation

Hypersensitivity

History of acute

porphyria

Long-term therapy

Use caution in

presence of renal

or hepatic

impairment.

Assess for

potential for

interactions with

other

pharmacological

agents patient

may be taking.

Evaluate results

of laboratory

tests, therapeutic

Monitor AST,

ALT, Serum

creatinine, signs

and symptoms

of peptic ulcer

disease, occult

blood with GI

bleeding.

Monitor renal

function to

correct dos.

effectiveness.