NAME: DRT AGE: 67 DIAGNOSIS: CVA 2° to HPN NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

S- “Sumasakit ang Acute Pain STG: 1.Perform pain -to determine the STG:
ulo ko kapag related to After 6 hours of assessment(location,duration,intensity,quality etiology of the Goal met,After 6
nagpupunta akong increased Nursing and characteristic) condition hours of Nursing
palikuran “, as Intracranial Intervention, the 2.Postion the client: HOB elevated with body -to decrease ICP Intervention, the
verbalized by the Pressure client’s level of in central position client’s level of
client. asmanifested by pain from 6/10 will 3. Provide quiet,calm and relaxing -to minimize pain pain from 6/10 was
flushing of skin. decrease into environment. decreased into
Pain Level= 6 3/10 4.Provide comfort measures -to minimize pain 3/10
5.Instruct the client to relax -to minimize pain
O- VS as follows: 6.Encourage diversional activities -to minimize pain
BP- 140/90 LTG: 7.Instuct the client to avoid going to -to decrease ICP LTG:
mmHg After 3 days of bathroom Goal met.After 3
T- 36.5°C Nursing 8.Instruct the client to avoid activities that -to decrease ICP days of Nursing
PR- 68 bpm Intervention, the may contribute to Increase Intracranial Intervention, the
RR- 19 cpm client will be free pressure client is free from
-Flushing of skin from pain 9.Administer pain medication as ordered by -to relieve or pain
-altered mental the physician control pain
status
-speech
abnormalities
-decreased
sensation on lower
extremities

NAME: DRT AGE: 67 DIAGNOSIS: CVA 2° to HPN NURSING CARE PLAN

 ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

S- “Sumasakit ang Acute Pain STG: 1.Perform pain -to determine the STG:
ulo ko kapag related to After 6 hours of assessment(location,duration,intensity,quality etiology of the Goal met,After 6
nagpupunta akong increased Nursing and characteristic) condition hours of Nursing
palikuran “, as Intracranial Intervention, the 2.Postion the client: HOB elevated with body -to decrease ICP Intervention, the
verbalized by the Pressure client’s level of in central position client’s level of
client. asmanifested by pain from 6/10 will 3. Provide quiet,calm and relaxing -to minimize pain pain from 6/10 was
flushing of skin. decrease into environment. decreased into
Pain Level= 6 3/10 4.Provide comfort measures -to minimize pain 3/10
5.Instruct the client to relax -to minimize pain
O- VS as follows: 6.Encourage diversional activities -to minimize pain
BP- 140/90 LTG: 7.Instuct the client to avoid going to -to decrease ICP LTG:
mmHg After 3 days of bathroom Goal met.After 3
T- 36.5°C Nursing 8.Instruct the client to avoid activities that -to decrease ICP days of Nursing
PR- 68 bpm Intervention, the may contribute to Increase Intracranial Intervention, the
RR- 19 cpm client will be free pressure client is free from
-Flushing of skin from pain 9.Administer pain medication as ordered by -to relieve or pain
-altered mental the physician control pain
status
-speech
abnormalities
-decreased
sensation on lower
extremities

NAME: DRT AGE: 67 DIAGNOSIS: CVA 2° to HPN NURSING CARE PLAN

 ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

S- “Sumasakit ang Acute Pain STG: 1.Perform pain -to determine the STG:
ulo ko kapag related to After 6 hours of assessment(location,duration,intensity,quality etiology of the Goal met,After 6
nagpupunta akong increased Nursing and characteristic) condition hours of Nursing
palikuran “, as Intracranial Intervention, the 2.Postion the client: HOB elevated with body -to decrease ICP Intervention, the
verbalized by the Pressure client’s level of in central position client’s level of
client. asmanifested by pain from 6/10 will 3. Provide quiet,calm and relaxing -to minimize pain pain from 6/10 was
flushing of skin. decrease into environment. decreased into
Pain Level= 6 3/10 4.Provide comfort measures -to minimize pain 3/10
5.Instruct the client to relax -to minimize pain
O- VS as follows: 6.Encourage diversional activities -to minimize pain
BP- 140/90 LTG: 7.Instuct the client to avoid going to -to decrease ICP LTG:
mmHg After 3 days of bathroom Goal met.After 3
T- 36.5°C Nursing 8.Instruct the client to avoid activities that -to decrease ICP days of Nursing
PR- 68 bpm Intervention, the may contribute to Increase Intracranial Intervention, the
RR- 19 cpm client will be free pressure client is free from
-Flushing of skin from pain 9.Administer pain medication as ordered by -to relieve or pain
-altered mental the physician control pain
status
-speech
abnormalities
-decreased
sensation on lower
extremities