NAME: Gundan, Rodamel A.

SECTION: BSN-3C

The 62y/o patient stumble while walking and fell down on the ground on May 5, 2020 and ignored it
because all he thought it is a mild bump but after three days he experienced nausea, vomiting, body
weakness, dizziness and acute headache with fever. He was brought to emergency hospital, upon
assessment the doctor ordered Laboratory exams and CT scan. It reveals blood clotting(hematoma) seen
in his subdural space. The patient was admitted with diagnosis of subdural hematoma left temporal area
with medication of Nalbuphine Hcl 10mg IV now then prn for pain, Mannitol 150ml IV bolus every 4
hours, omeprazole 40mg IV OD and Cefoxitin 500mg IV every 8 hours.

Formulate 3 NCP according to patient priority needs

ASSESSMENT DIAGNOSIS PLANNIN INTERVENTION RATIONALE EVALUATI

G ON
Objective: Ineffective After 8 1. Assess 1. These After 8
 Adventitio airway hours of respiratio signs and hours of
us breath clearance nursing n and symptom nursing
sounds related to interventi breath s are interventi
such as hypoventila ons, the sounds, indicative ons, the
ronchi and tion patient noting of patient
wheezing secondary will be rate and respirator was able
 Presence to brain able to sounds y distress to
of whitish, stem injury manifest ( tachypn and/ or manifest
tenacious breath ea, accumula breath
secretions sounds stridor, tion of sounds
approxima crackles, secretions
tely 20 cc wheezes) 2. To
 Decreased 2. Evaluate determin
level of cough/ e ability
conscious gag reflex to protect
ness and own
swallowi airway
ng ability 3. Maintaini
3. Assess ng the
airway airway is
for always
patency first
4. Assess priority,
changes especially
in mental in cases
status of trauma
4. Lethargy
and
somnolen
ce are
 late signs

ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO

S N
Objective: Ineffective After 1 day 1. Assess 1. To check After 1 day
 Both eyes cerebral of nursing mental for of nursing
with tissue intervention status and affected intervention
negative perfusion s, the changes in cranial s, the
reaction to related to patient will the level nerve patient was
light the be able to of functions able to
 Restlessne interrupti improve conscious in the improve
ss on of the level of ness brain, level of
 Memory blood flow consciousne 2. Position check for consciousne
loss to the ss client in cerebral ss
 Behaviour brain low- hypoperf
changes fowler’s usion and
 Altered position hypoxia
consciousn 3. Avoid 2. Help
ess extreme venous
rotation drainage
of the from the
neck brain and
4. Avoid promote
extreme brain
hip flexion expansion
5. Maintain 3. This will
patent compress
airway the
6. Restore or jugular
maintain veins
fluid leading to
balance an
increased
intracrani
al
pressure
4. Increase
in intra-
abdomina
l and
intra-
thoracic
pressure
leading to
 increased
intracrani
al
pressure
5. Prevents
build-up
of
secretions
leading to
increase
in carbon
dioxide
and
intracrani
al
pressure
6. It
maximize
s cardiac
output
and
prevents
decreased
cerebral
perfusion
associate
with
hypovole
mia.

ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATI

S ON
Objective: Impaired After 4 1. Monitor 1. To provide After 4
 Limited physical days of patient’ baseline days of
range of mobility nursing s vital data nursing
motion related to interventio signs 2. Identifies interventio
 Inability sensory n, the 2. Review probable n, the
to perceptua patient will function functional patient
perform l be able to al impairments was able to
gross impairme maintain/ ability and maintain/
motor nt increase and influences increase
skills secondary strength reasons choices of strength
 Difficulty to injury, and for intervention and
upon bed rest function of impair s function of
 turning and affected ment 3. Maintains affected
 Unable to unrespons and/or 3. Provide mobility and and/or
transfer ive state compensat / assist function of compensat
to bed ory body with joints/ ory body
 Decrease part and range of functional part and
d muscle regain motion alignment of regain
strength optimal exercise extremities optimal
position s and reduces position
function as 4. Place venous function as
evidenced the stasis evidenced
by absence client in 4. Designated by absence
of designa therapeutic of
contractur ted position contractur
es and foot therape should es and foot
drop utic cause no drop
position undue stress
5. Elevate on muscles
the or joint
head of 5. The head of
the bed the bed may
as be elevated
appropr to provide
iate counteractio
n of for
comfort if
permitted