NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: >Ineffective tissue >SHORT TERM GOAL: >INDEPENDENT: >SHORT TERM GOAL:
> VITAL SIGN: perfusion related to  After 3-5  Monitor and  Assess the  After 3-5 hours
B/P-180/100mmHg bleeding as evidenced hours of document the level of of nursing
RR-20bpm by altered level of nursing neurological consciousness intervention the
HR-142bpm consciousness, (s) intervention status and sign for patient will be
TEMP-36.8 C changes in vital sign the patient frequently and increase ICP able to
O2SAT-95% and changes in motor will be able to compare at the and it is useful verbalized and
response verbalize, and baseline. to determine understand of
understand of the his/her
his/her  Monitor the progression of condition.
SUBJECTIVE: condition. vital sign, take CNS damage.
>chest pain notes of the
>headache Blood Pressure,  Fluctuations in
>dizziness >LONG TERM GOAL: and the heart vital sign may >LONG TERM GOAL:
 After 2-3 days rate, occur because  After 2-3 days
of nursing of cerebral of nursing
intervention >DEPENDENT: pressure with intervention the
the patient  Administer injury in patient will be
will be able to antihypertensive vasomotor able to
demonstrate as ordered. area of the demonstrated
the increase brain. the increased
perfusion as  Administer stool perfusion as
individually softeners as individually
appropriate. ordered. appropriated.
Vital sign on Vital sign on
normal range, normal range,
alert and alerted and
oriented. oriented.
>After our nursing
care the feeling of the
patient are in good >after our nursing care
condition.  Chronic the feeling of the
hypertension patient are in a good
requires condition.
cautious
treatment
because the
aggressiveness
management
due to
increase the
risk of the
tissue
damage.

 To prevent the
straining
during the
bowel
movements
and
corresponding
increase ICP.