Saint Louis University School of Nursing Baguio City

Nursing Care Plan: Proper

Submitted to: Mrs. Ma. Theresa Macaraeg, RN

Submitted by: SAYSON, John Mark C. BSN III E3

June 2012

NCP # 1: Hypertension, CAD ASSESSMENT S> Nu sag paminsan ket agsakit met daytoy ko (nape) ken maul-ulaw ak pay. O>with vital signs of: Elevated BP 130/100mmHg Decreased PR 58bpm weak and irregular RR 18cpm To 36oC >appears weak >alert and oriented >with capillary refill of 2 seconds >skin is cool to touch >negative edema noted >patient was ordered for CBR without BRPs A>Ineffective Tissue Perfusion [Peripheral and Cardiopulmonary] related to altered hemodynamics

EXPLANATION OF THE PROBLEM It is a decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. The tissues perfusion problems can exist without decreased cardiac output and tissue perfusion. It happens when the arteries that supply blood to heart muscle and to other parts of the body that become hardened and narrowed. This is due to the buildup of cholesterol and other material, called plaque, on their inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain or a heart attack and in the case of the patient elevated blood pressure.

GOAL AND OBJECTIVES Goal: The patient will manifest stable vital signs specially the BP. LTO>After 3 days of collaborative care the patient will demonstrate an increase in perfusion as evidenced by: 1. Strong peripheral pulses 2. Vital signs within normal range 3. Maintained the absence of edema 4. Maintained mental status STO>After 8 hour shift of collaborative management the patients BP will decrease from 130/100mmHG to 120/80mmHG

INTERVENTION Monitor Blood Pressure

RATIONALE To gather baseline data and identify possible occurrence of complications. To gather baseline data and to compare existing assessment which can be used as tool in assessing clients status or response to therapy To continuously monitor for changes throughout the contact with the patient. To determine complications such as pulmonary emboli and hypoxia, and to provide early interventions. To determine adequacy of oxygen in the peripheries by mainly assessing the time at which blood refills the capillaries A high cardiac workload can eventually lead to the veins, lungs and tissues becoming full of backed up fluid causing congestion To conserve energy and lower tissues oxygen demands Drug response and toxic levels may be altered by

EVALUATION

Palpate for the quality of pulses

Assess level of consciousness

Observe for signs of chest pains, cyanosis and respiratory distress

Measure capillary refill

STO>After 10-15minutes of health teaching, the client and the SO will verbalize understanding of: a. Hypertension Reference: Medical Surgical including its causes, th Nursing by Ignatavicius 6 prevention, and Edition management b. Therapeutic regimen including pharmacological and non-pharmacological management

Caution the client to avoid activities that increases cardiac workload

Provide quiet environment conducive for rest Administer medications with caution

decreased tissue perfusion Assist in ambulation and positioning To limit energy consumption and respiratory effort. To avoid gasping of air causing tachypnea, this provides inadequate oxygen to the body. For the client to understand benefits of adhering to the therapeutic regimen and to include the client in the management. To alert the health care team and provide early intervention. To prevent complications. To provide knowledge about hypertension.

Reinforce importance of strict adherence to therapeutic regimen

Instruct to verbalize unusual discomfort such as dizziness, pain and respiratory discomfort Educate about Hypertension including its causes, prevention and management. Ascertain nonpharmacological management of hypertension such as rest and HWB on the nape area

For the patient not to rely on medications but also to nonpharmacological management which has less side effects.

References: Medical Surgical Nursing by Ignatavicius 6th Edition Medical and Surgical Nursing by Brunner and Suddarth 10th Edition

NCP # 2: Immobility caused by stroke ASSESSMENT EXPLANATION OF THE PROBLEM S>Hindi pa siya naliligo at nag This is a state in which a toothbrush simula nung na person experiences a confine siya dito sa hospital. difficulty in performing tasks of daily living, such as O> dressing, feeding, bathing, FEEDING: and toileting. The patient had inability to handle utensils a history of stroke last 2010 with both hands which resulted to paralysis of inability to prepare food and right upper extremities. open containers Motor deficits are the inability to chew foods that obvious effect of stroke. are difficult to masticate Symptoms are caused by DRESSING: destruction of neurons in the Inability to put on and pyramidal pathways, this are remove clothes by himself nerve fiber in the brain and BATHING: passing to the spinal cord to Patient was ordered for CBR the motor tract. without BRP thus patient is Paralysis is the complete loss restricted to get out of the of muscle function for one or bed to bathe with assistance more muscle groups. of the relatives. Paralysis can cause loss of TOILETING: feeling or loss of mobility in Patient was ordered for CBR the affected area. As a result, without BRP thus patient is patient is now assisted by his using adult diapers. family. A>Self Care Deficit [Feeding, Bathing, Dressing and Toileting] related to musculoskeletal impairment secondary to stroke Medical Surgical Nursing by Ignatavicius 6th Edition

OBJECTIVES LTO> After 3 days of nursing intervention, patient will demonstrate techniques or lifestyle changes to meet selfcare needs. STO> After 10-15 minutes of nursing interventions, patient will identify personal resources that can provide assistance and be able to verbalize knowledge of health care practices. STO> After 5-10 minutes of health teaching on ROM exercises, the client and SO will verbalize understanding regarding its importance, benefits, and how it is done.

INTERVENTION Establish rapport

RATIONALE To gain trust and cooperation not only to the client but also to the family. Provides data regarding mobility and ability to perform activities within limitations without injury and frustrations. To identify hindrances that can affect the adherence to therapeutic regimen. To identify developmental level to which client can understand. Promotes muscle tone, circulation, joint flexibility, prevents contractures and weakness. Provides safe support for immobility and other self-care activities to promote independence if tolerated.

EVALUATION

Assess for type and severity of immobility, impairment, muscle flaccidity, spasticity and coordination

Assess barriers to participation

Assess memory / intellectual functioning

Provide passive ROM to the affected site and active ROM on other limbs as tolerated

Use assistive devices appropriate for personal hygiene such as articles for brushing teeth and clothing that is easily managed to dress and undress Educate on ROM exercises and health practices

To share knowledge on ROM exercises and health practices that can help to patient giving self-care.

References: Medical and Surgical Nursing by Brunner and Suddarth 10th Edition Fundamentals of Nursing by Potter and Perry 3rd Edition