University of Massachusetts Dartmouth College of Nursing
Patient Care Plan
Student Name: Emily Cerrone Patient Diagnosis: concussion Age/Sex: 11/M
ASSESSMENT PLANNING
Nursing Diagnosis
in correct format Expected Outcome with Time
(Select one from Concept Frame
Map)
NSG DX General Goal
Ineffective cerebral By the end of next week,
tissue perfusion r/t the patient will no longer
be experiencing headaches
neurological injury AEB
headache. and will report 0/10 pain
Expected Outcome
By the end of next week, GCS
the pt will no longer be
experiencing headaches
with no additional
symptoms. The pt will
continue to rest for
another week while
reporting if headaches
come back.
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Date of Care: 11/29/18 Setting: Brown Elementary
IMPLEMENTATION
List Nursing Interventions
1) Assess pain level
2) Monitor vital signs
3) Assess eyes for
PERRLA
4) Assess LOC using
5) perform neurological
tests, monitoring gross
and fine motor skills
6) Allow patient to rest
and lie down in office
RATIONALE EVALUATION
Rationale for Nursing
Evaluate patient response to
Interventions, Scientific
interventions.
Principle, References
1) pt reports a headache The pt responded well to the
which is a sign of
ineffective cerebral tissue interventions as all of them
perfusion. If it gets worse
were completed.
than that can indicate that
the perfusion is decreasing Reassessment will be done to
further
see if the perfusion returned
2) if alterations occur in the
back to baseline in a week but
vials like decrease RR, then
that can indicate a decrease in aside from the increased pain
cerebral perfusion because of
a change in consciousness and headache, all other
3) Decrease perfusion can
findings were normal.
alter the eyes and their
Did Patient Achieve Expected
reactivity. PERRLA is Outcome? Explain why or why not.
pupils are equal and
reactive to light The patient will be reassessed
4) LOC can decrease as
in a week to see if he met his
perfusion decreases.
goal.
5) decreased perfusion can
manifest as decrease motor
skills What needs to be changed?
6) the brain needs time to rest At this time nothing needs to be
and heal so that the perfusion changed but this will be considered
can return to baseline after he is reassessed in a week.