CUES NURSING SCIENTIFIC GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS BASIS OUTCOME ACTIONS AND

CRITERIA NURSING ORDERS

S- “Di naman Disturbed thought Cerebrovascular After 2 weeks Nursing order:

cya mo tingog” process related to disease is a group of comprehensive nursing Render nursing
as verbalized by Bleeding brain dysfunctions intervention, the patient purposeful
S.O Hypertensive related to disease of will be able to improve interventions that will
CVD the blood vessels Level Of help patient improve
O- patient is supplying the brain. Consciousness. LOC.
seen lying on Hypertension is the
bed, most important Specifically, the patient, Nursing Action:
unresponsive to cause; it damages together with his S.O.
questions. the blood vessel will be able to: 1.) monitor vital To watch patient for GOAL NOT MET:
lining, endothelium, signs abnormalities
V/S exposing the 1.).verbalize Patient is still unresponsive
underlying collagen understanding of to question
T=36.6 C where platelets disease process
P=60bpm aggregate to initiate
R=16cpm a repairing process 2.)improve LOC
BP=130/70m which is not always
mHg complete and 2.) Encourage SO Provides patient with an
perfect. to participate opportunity to regain
in level of consciousness
reorientation
and provide
ongoing input.
3.) Provide safety To prevent dangers
measures as from happening
indicated.
 NURSING CARE PLAN
Patient’s Name: _________I.J.,______________________ Hospitalno.:_100022601885 ________
Age: _____________73____________________________ Room no.:__ _M6________________
Impression/Diagnosis: Bleeding Hypertensive CVD___ Physician:______Dr. Iben Ting_______
Nurse’s Name & signature: __________________________

CLINICAL PORTRAIT PERTINENT DATA

Received patient lying on bed, semi-conscious, responsive to pain stimulus, with ETT Few hours PTA, patient suddenly lost consciousness and was
attached ti mechanical ventilator, with pulse oximeter, with NGT, with FBC to brought by her relatives to CHH due to unresponsiveness
urobag, with IVF# 12 PLR 1L + 20 mEq KCl @ 120ct c/min infusing well on right
foot with the following vital signs: V/S taken during admission:

T= 36 C
T= 37.5 C P=43bpm
P= 65bpm R=246/182mmGh
R=17cmp Ht= 160 cm
BP=120/60mmHg Wt=55kg