NURSING CARE PLAN

Patient’s Name:​ E.A.O Hospital No.: ​25899

Age:​59 YO ​Room No.:​ 615

Impression Diagnosis: ​Acute CVD haemorrhage, Left Lentiform Nucleus Physician:​ Dr. Batoctoy,Brett

Nurse’s Name and Signature: ​JINKY V. ARDIENTE

CLINICAL PORTRAIT PERTINENT DATA

1. Assessment (general impression from head to toe) 1. History of present illness
Received lying on bed, awake, afebrile, coherent with ongoing A case of E.A.O, 59 years old, female, married, residing Basak
PNSS at 80cc/hr hooked at left arm infusing well, not in San Nicolas Cebu City
respiratory. Early afternoon patient had sudden onset of right sided weakness
and slurring of speech
2. Significant Findings 2. Chief complaints
Decreased performance, lethargic Body weakness, slurring of speech
3. Vital signs taken during the nurse’s first contact with the 3. Health history relevant to present illness
patient HCVD or amlodipine
Temperature: 36.2℃ Status Post Thyroidectomy
Heart rate: 86BPM 4. Vital signs taken during admission
Respiratory rate:20 CPM Temperature: 36.5 degree Celsius
O2 sat: 99% Heart rate: 90BPM
BP: 130/90 Respiratory rate: 20CPM
BP: 140/90

5. Laboratory results regardless of findings

​CT Scan 01/017/2020
Impression: acute haemorrhage in the left lenticulocapsular region
9approximately 8.1 cc in volume) with minimal surrounding
edema and mass effect.

Radiologic Findings 1/03/2020

Impression: therosclerosis of the thoracic aorta
 CUES NURSING SCIENTIFIC GOAL AND NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME ACTION AND OF NURSING
ORDERS ORDERS
Subjective Risk for injury Seizures are After 8 hours of Independent: Goal Met:
related to loss of disturbances in nursing 1. Establish -to have good After 8 hours of
“nikalit ra syag
large muscle normal brain intervention the ed rapport nurse-client nursing
kirig-krig coordination. function caregiver will relationship interventions,
resulting from verbalize 2. Monitor -establish a the caregiver
ma’am nga abnormal understanding of vital signs baseline data verbalized
murag dili nya electrical individual 3. Explore -lack of sleep, understanding of
discharges in the factors that with the flashing lights individual
ma control” as brain which can contribute to caregiver the and prolonged factors that
verbalized by cause loss of possibility of various stimuli television contribute to
consciousness, injury and take that may viewing may possibility
the mother. uncontrolled steps to correct precipitate cause potential injury and took
body situation(s). seizures activity seizure activity. step to correct
movements. -enables the situation.
Objective: Specifically: 4. Discuss patient to
-weakness 1. seizure warning protect self from
signs and usual injury
-irritability (doenges,et.al… seizure pattern
- active tonic ….2016)
Dependent:
and clonic 1. Administ -relieve severity
seizure er prescribed of seizure
medication
-frequent
blinking of the Collaborative:
1. Collabor -to prevent the
eyes ate with the patient from any
caregivers for injury
-small for age
preventive
 measures to
avoid
Vital signs:
unnecessary
Temp: 36.7 accident during
seizure. -regular check
HR: 125 BPM 2. Refer to up help to
RR: 37 CPM neurologist for determine any
further progress in the
02 sat 99% examination patient’s
Include: condition
*laboratoty
*xray
*EEG result
 CUES NURSING SCIENTIFIC GOAL AND NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME ACTION AND OF NURSING
ORDERS ORDERS
Subjective: Delayed growth A growth delay After 8 hours of Independent: Goal partially
“pag 2 months and development occurs when a nursing 1. ​Demonstrate -proper met.
palag niya maam related to child isn’t intervention, the methods that education to the After 8 hours of
nakabantay mi abnormalities in growing normal caregivers will allow parents will help nursing
nga wala kaayo cognitive rate for their age. verbalize parents/family to us identify which intervention the
sya nidako” as function The delay may understanding of participate procedure needs caregiver will
verbalized by the caused by an growth and in child’s care. to be modify verbalized
mother underlying developmental 3. Increase -constant care understanding of
health condition, delay and plan(s) stimulation by and love to the growth and
Objective: such as growth for intervention. using child will help developmental
-Inability to hormone various-colored him develop his delay and plan.
perform deficiency or toys in crib social motor .
self-control hypothyroidism. (e.g., mobiles, skills by utilizing
activities (www.healthline musical toys, various toys
appropriate for .com) stuffed toys of appropriate for
age varied textures) his age.
-unable to lift his and
own head frequently
without a holding and
support speaking to the -to identify if the
-cannot sit alone infant. mother lacks of
-lack of response 4. Observe knowledge in
when cuddled mother and child caring her child
*anthropometric during that may result in
measurements* interaction, deprivation of
Height: 59 cm especially during child’s
Weight: 3.24kg feeding. development
Head DEPENDENT: -vitamins
circumference: 1. Administ supplements will
35 cm er prescribed help provide all
Chest medication and the necessary
circumference: vitamin vitamins that
37 cm supplements. lack in the
  child’s nutrition
 
Vital signs: COLLABORATIVE:
Temp: 36.7 1. Refer to
HR: 125 BPM dietary section -collaborate to
RR: 37 CPM for nutrition nutritionist to
02 sat 99% counseling  assist child’s
nutrition to be
given that is
appropriate in his
age to promote
proper growth
and
development..