Name: D.

E
Age: 41 years
Diagnosis: Epilepsy
Nursing Care Plan
Assessment Diagnosis Goal Intervention Evaluation
Subjective Ensure patient Stress the Patient was given
Risk for receive importance of medication on
Pt is a 42year old fall and medications on taking medication time
male injury time regularly
related to The patient and
He is a seizure seizure Monitor patient Monitor patient for family was
patient activity regularly signs of toxicity educated about
hospital
Has a history of Ineffecive Monitor, asses monitor patient for procedure and
HTN breathing and document dizziness, nausea when to notify
patterns as seizure and vomiting the staff
Has an edema to evidenced activities
the lower by monitor patient for Family members
extremeties abnormal Monitor patients toxic adverse effects were given
rate, vital signs to medication emotional
Uses lasix for the rhythm and support
edema depth Normal place patient on side
breathing during seizure to
Objective pattern adequate prevent aspiration
to meet oxygen
Dilantin 100mg need do not restrain the
IV, Tid patient during a
siezure
Valium 10mg IV
Monitor patient
V/S SPO2
BP- 150/100, R-
32, P- 80, Temp- Rationale
99o F To prevent patient
from getting into
contact with
harmful objects

To prevent patient
from risk for fall

Prevent patient from

injury
Name: A. P
Age: 61 years
Diagnosis: Acute Coronary Syndrome (ACS)
Nursing Care Plan

Assessment Diagnosis Goal Intervention Evaluation

Subjective Acute pain Relieve chest Monitor patient Patient vital
evidenced by pain vital signs and signs returned to
Patient is a 61 myocardial stabilize heart Spo2 normal
year old male infraction rhythm
Ensure patient Patient was
He is an ACS Administer receives educated about
patient medications medications on the drugs given
time and the
He is a known importance of
HTN Monitor patient each drug
regularly
He has a Family was
bacterial place patient in encouraged to
Infection of comfortable ensure that the
which he uses position patient takes all
ceftriaxone drugs as required
teach patient after discharge
Patient stated relaxation
that he had techniques
tightness of Rationale
chest slight pain
To ensure
Objective normal blood
pressure
Grimacing To prevent any
V/S further elevation
BP 175/100
temp- 99.8oF To ensure that
Resp. 33bpm the patient is
Pulse 86bpm signs and
symptoms does
SPO2 96% not prolong