NURSING CARE PLAN

Nursing care plan 1

Date/ Time 30/01/13 @10pm Nursing problem Goal Ineffective breathing related to disease process ( impending respiratory failure due to GCS drop 9/15 and lost of consiousness) Patient will able to breath in normal range without any ventilator support. Nursing action 1. Monitor vital sign hourly BP, HR, RR, SPO2. Connect patient airway to ventilator with correct setting as set by DR Monitor ABG and ventilator parameter. Inform DR if abnormalities detected. Monitor patient for cyanosis, pallor and sign of hypoxia. Do ETT suctioning as indicated. Auscultate chest for bilateral equal air entry. Document vital sign hourly. Evaluation Patient able to weaning off ventilator and was on trachy mask O2 on 7/2/13. ABG show good oxygenation and pateint bearth in normal range.

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Nursing care plan 2

Date/ Time Nursing problem Goal Patient will maintain normal body temperature 36.5 c 37.4c Nursing action 1. Monitor body temperature 4hourly . 2. Dress patient with light cloth or linen. 3. Perform tepid sponging if temperature > 38c 4. Give adequate hydration. 5. Serve antipyretic as prescribe by DR. 6. Document temperature, vital sign and intervention done. Evaluation Patients body temperatur e 36.5c 0n 4/2/13 @ 8am. 03/02/13 Altered body @ 10am. temperature (hyperthermia) related to disease process as evidence by high body temperature 38.2c

Nursing care plan 3

Date/ Time 06/02/1 3@ 9.30pm Nursing problem Low cardiac output (hypotension) related to disease process (post op) evidence by BP 90/53 105/48mmhg. Goal Patients BP able to maintain at normal range with target MAP >90mmhg and SBP 140160mmhg. ( for neuro patient) during hospitalization. Nursing action 1. Monitor and document BP and MAP continuously and inform doctors for abnormality 2. Give fluids challenge as ordered and ensure patient have good hydration. 3. Infused inotropes as prescribed and tirtrate accordingly to BP. 4. Monitor CVP reading and inform DR if any abnormality. Evaluation Patient BP and MAP able to maintain in normal range and inotrope able to off on 7/2/13 @ 5am.

Nursing care plan 4

Date/ Time Nursing problem Goal Patient will be maintain his personal hygiene during hospitalization. Nursing action 1. Perform bedbath or pressure area treatment every shift. 2. Perform eye toilet and oral care 3. Do skin asesment and document it . 4. Apply sanyrene at prominent body to promete blood circulation. 5. Change all dirty linen or wet linen as needed. 6. Applly paraffin cream to lips to moisture it and prevent dryness. Evaluation On 8/2/13 @ 4.30pm: patient transfer out to neuro ward. ADL done and patient;s skin integrity intact during stay in ICU. 30/01/13 Self care @ 11pm. deficit due to hospitalization

Nursing care plan 5

Date/ Time 5/2/13 @ 8am Nursing problem Potential to infection related to invasive procedure: 1. Arterial line 2. CVP line 3. EVD 4. Trachy tube. Goal Patient will free from infection during hospitalization. Nursing action 1. Maintain aseptic technique during the procedure insertion or dressing of insertion. 2. Observe sign of infection e.g. raise body temp., TWC, RH, and lowish BP. 3. Observe sign of infection at insertion site. 4. Observe colour, nature of secretion from trachy. 5. Sent specimen/ sample for C&S. Evaluation