GOLEZ, Steffi Gabrielle R.

4NUR-2 RLE-2 – Ma’am Dyan Dee Tiongco

PATIENT CARE RECORD – NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC GOALS/ OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS
Subjective: Ineffective The presence of Short Term: INDEPENDENT: Short Term:
“Na stroke si cerebral partial blockage Within 8 hours of nursing Within 8 hours of
mama.” As tissue of the blood interventions, the client will be -Establish rapport -To promote nursing interventions,
verbalized by perfusion vessel can be able to: cooperation the client was able to:
the client’s related to multifactorial.
daughter. interruption These can be  Demonstrate stable -Assess factors -Assessment • Demonstrated stable
of blood due to vital signs and absence related to individual will vital signs and absence
Objectives: flow vasoconstriction, of signs of increased situation for determine and of signs of increased
-GCS: 4 secondary to platelet ICP. decreased cerebral influence the ICP.
-Extremity hemorrhage adherence on  Display no further perfusion and choice of • Displayed no further
weakness: as evidenced rough surface, deterioration/recurrence potential for interventions. deterioration/recurrence
paralysis by GCS 4. fat accumulation of deficits increased ICP. of deficits.
and therefore
V/S as decreases -Closely assess and -Assesses Long Term:
follows: elasticity of Long Term: monitor neurological trends in level Within 3 days of
-BP: vessel wall Within 3 days of nursing status frequently and of nursing interventions,
150/90mmHg leading to interventions, the patient will: compare with consciousness the patient was able to:
-PR: 146 alteration of baseline. (LOC) and
 Maintain usual or
-RR: 21 blood perfusion potential for • Maintained usual or
-Temp: 37.9C with the improved LOC, increased ICP improved LOC,
initiation of the cognition, and motor and and is useful cognition, and motor
clotting sensory function. in and sensory function.
sequence. This determining
may later lead to location,
the development extent, and
 of thrombus progression of
which can be damage.
loosened and
dislodged in Monitor Vital Signs:
some areas of
the brain such as -Changes in blood -Fluctuations
mid cerebral pressure, compare in pressure
carotid artery BP readings in both may occur
that may lead to arms. because of
alteration of cerebral
blood perfusion injury in
and further vasomotor
develop to area of the
cerebral brain.
infarction.
-Heart rate and -Changes in
Source: medical rhythm, assess for rate,
surgical nursing: murmurs. especially
13th Brunner’s bradycardia,
and Suddarath’s can occur
because of the
brain damage.

-Respirations, noting -Irregularities

patterns and rhythm. can suggest
location of
cerebral insult
or increasing
ICP and need
for further
intervention,
including
possible
 respiratory
support.

-Position with head -Arterial

slightly elevated and pressure by
in neutral position. promoting
venous
drainage and
may improve
cerebral
perfusion.

-Maintain bedrest, -Continuous

provide quiet and stimulation or
relaxing activity can
environment, restrict increase
visitors and intracranial
activities. pressure
(ICP).
Absolute rest
and quiet may
be needed to
prevent
rebleeding in
the case of
hemorrhage.

-Assess for nuchal -Indicative of

rigidity, twitching, meningeal
increased irritation,
restlessness, especially in
hemorrhage
irritability, onset of disorders.
seizure activity. Seizures may
reflect
increased ICP
or cerebral
injury,
requiring
further
evaluation
and
intervention.
COLLABORATIVE:

-Administer -Reduces
supplemental oxygen hypoxemia
as ordered

-Administer -To promote

medications as wellness
ordered