Nursing Care Plan ASSESSMENT Subjective: Hindi ko maigalaw ang aking kaliwang kamay at medyo hindi ko rin maigalaw

ang kaliwa kong paa. Objective: Left hemi paralysis Limited range of motion (ROM) Functional level: level 2-requires help SCIENTIFIC EXPLANATION Impaired physical mobility related to neuromuscular impairment INFERENCE Neuromuscular disorders affect the nerves that control the voluntary muscles. Voluntary muscles are the ones that can be controlled, like in the arms and legs. The nerve cells, also called neurons, send the messages that control these muscles. When the neurons become unhealthy or die, communication Long term After 4 months of continuous ,effective and collaborative nursing interventions, After 4 hours, the patient verbalize understanding situation or risk factors and individual treatment regimen and safety measures Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation The longer the patient remains immobile the After 4 months of continuous ,effective Determine the diagnosis that contributes to immobility To be informed about the restrict movements PLANNING Short term INTERVENTION Monitor V/S RATIONALE To note changes and for baseline comparison. EVALUATION After 4 hours of nursing intervention the patient was able to verbalize understanding situation or risk individual treatment regimen and safety measures

situations that may factors and

greater the level of and collaborative nursing debilitation that will occur interventions, patient was able to maintain position and function

between the nervous patient will

from another person.

system and muscles breaks down. As a result, the muscles weaken and waste away. The weakness can lead to twitching, cramps, aches and pains, and joint and movement problems. Sometimes it also affects heart function and ability to breathe. Many neuromuscular diseases are genetic, which means they run in families or there is a mutation in your

maintain position, function and skin integrity Perform passive or active ROM exercises to all extremities increased venous return, prevents stiffness, and maintains muscle strength and endurance Turn and position every 2 hours or as needed. This optimizes circulation to all tissues and relieves pressure. Provide safety measures(side rails, using pillow to support body part) To provide safety and reduce the risk of pressure ulcers

and skin integrity as Exercise promotes evidenced by the absence of contractures, footdrop, decubitus and so forth

genes. Sometimes, an immune system disorder can cause them. Most of them have no cure. The goal of treatment is to improve symptoms, increase mobility and lengthen life.

Massage back and bony prominences

It provides comfort to the patient and promotes good circulation

Consult with physical or occupational therapist as indicated

To develop individual exercise therapy or program

Reference: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=35

ASSESSMENT

SCIENTIFIC EXPLANATION

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Hindi ako mapadumi. Objective: Abdominal pain, urgency Altered bowel sounds Left Hemi paralysis Limited ROM Constipated for five days

Constipation related activity

A decrease in a frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool. A lack of physical activity can lead to constipation. For example, constipation often occurs after an accident or during an illness when one must stay in bed and cannot exercise. Lack of

After 8 hours, the patient will establish or return to normal patterns of bowel functioning

Determine stool color, consistency, frequency and amount

Assist in identifying causative and contributing factors and appropriate interventions

After 8 hours, the patient was able to establish or return to normal patterns of bowel functioning as evidenced by easy passage of long, round, and smooth brownshaded stool with a texture similar to creamy peanut butter

to insufficient physical person's normal

Auscultate bowel sounds

Bowel sounds are generally decreased in constipation

Encourage increased fluid intake, 2500-3000 ml/day within cardiac tolerance

Assists in improving stool consistency

Encourage to eat high-fiber rich

To enhance easy defecation

physical activity is thought to be one of the reasons constipation is more common in older people. Moreover, increased physical activity is more likely to stimulate bowel motility and improve the symptoms of constipation.

foods Decrease gastric Recommend avoiding gasforming foods distress and abdominal distention Prevents skin Assist in perianal skin condition frequently, noting changes or beginning breakdown Facilitates Discuss use of stool softeners, mild stimulants, bulkforming laxatives, or enemas as indicated. Monitor defecation when constipation is present excoriation and breakdown

effectiveness Constipation is a Identify factors (e.g., medications, bed rest, diet) that may cause or contribute to constipation. Evaluate medication profile for gastrointestinal side effects. Fiber absorbs water, which adds Consult dietitian to provide wellbalanced diet high in fiber and bulk bulk and softness to the stool and speeds up passage through the intestines common side effect of many drugs including narcotics and antacids.

Reference: http://www.med.umich.edu/1libr/aha/umconstipation.htm

ASSESSMENT SUBJECTIVE: ayoko kumain ng walang lasa OBJECTIVE: >pale to pinkish conjunctiva and lips >weak looking >fair appetite, selective with food preferences

DIAGNOSIS Impaired adjustment related to health status requiring change in lifestyle

SCIENTIFIC EXPLANATION Inability to modify lifestyle in a manner consistent with a change in status. The objective of nursing care for focuses on lowering and controlling the blood pressure without adverse effects and without undue cost. To achieve these goals,

PLANNING Short Term Goal After 4 days of nursing intervention, there will be an increase interest and participation on the

INTERVENTION Independent Vital signs monitored and recorded. BP monitored regularly

RATIONALE

EVALUATION After 4 days of

For baseline comparison

nursing interventions the goal is met through participation and demonstration of lifestyle changes

hypertensive patients demonstration of self care and will initiate lifestyle changes that will permit adaptation to present medical situation

Assist the patient in These risk factors identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol have been shown to contribute to hypertension

BP-130/90 mmHg

the nurse must support and teach the patient to adhere to the treatment regimen by implementing necessary lifestyle changes like avoidance of foods high in sodium and fats and taking medications as prescribed.

Instruct and emphasize necessary care and lifestyle changes that will enhance her recovery.

This will promote trust and will on the patient to adhere to such activities that will enhance fast recover

Plan necessary care and assistance in ADLs with the relative Emphasize the importance of adequate rest Emphasize the importance of adherence to

Planning with the relative will add more cooperation of the patient This will lower the patients BP

Hypertension needs medications to maintain the BP

medications Provide an open environment encouraging communication

in its normal range Expression of feelings concerning impaired function is dealt with realistically

Reference: http://www.medicinenet.com/high_blood_pressure/article.htm

DRUG STUDY Nursing Name of Drug Classification Indications Side Effects Contraindications Responsibilities Monitoring Parameters

Generic Name:

Miscellaneous Fluids or Diuretics Action -increase osmotic pressure of glomerular filtrate which inhibits tubular re-absorption of water and

Reduction of increased intracranial pressure associated with cerebral edema

Dizziness Headache Convulsions Blurred vision Diuresis Dry mouth Loss of hearing

Hypersensitivity Severe renal disease Severe dehydration Pulmonary congestion

Assess patients condition before therapy and regularly thereafter to monitor drug effectiveness

Monitor vital signs, CVP, and urine specific gravity

Mannitol Brand Name:

Osmofudin 20% Route and Frequency: IV q4 Dose:

Monitor manifestations of electrolyte imbalance

Reduction of increased ocular pressure

Assess for possible drug induced adverse reactions.

Assess BP before and during the therapy with patient lying, standing and sitting, orthostatic hypotension can occur rapidly.

Promotion of diuresis in the prevention and/or treatment for oliguria or anuria due to acute renal failure

electrolytes and increases urinary output

100 cc

Assess patient for possible drug induced adverse reactions. Teach patient to recognize and immediately report adverse reactions

Asses patients and familys knowledge of drug therapy

Nursing Name of Drug Generic Name: Citicholine Brand Name: Classification CNS stimulants or Neurotonics Action Indications CVA in acute and recovery phase. Signs and symptoms of cerebral insufficiency. Recent cranial trauma Parkinsons disease Cytidine Diphosphate -A derivative of choline and cytidine Choline involved in the Route and Frequency: IV q12 Dose: 1 gm biosynthesis of lecithin. It is claimed to increased blood flow and oxygen consumption. Side Effects Shock Hypersensitivity Hypotension Insomnia Stimulates parasympathetic action and fleeting and discreet hypotension effect Contraindications Hypertonia of the parasympathetic nervous system Pregnancy and lactation Responsibilities Evaluate patient medical history Assess patient condition Should not be administered to patient with hypertonia of the parasympathetic nervous system Caution that large doses could aggravate

Monitoring Parameters Monitor vital signs Assess allergic reaction like GI disturbances

increase in cerebral blood flow in episodes of persistent intracranial hemorrhage. Teach patient to gain benefits and not to miss any dose

Nursing Name of Drug Classification Indications Side Effects Contraindications Responsibilities

Monitoring Parameters

Generic Name:

Cardiovascular Statins Action -Inhibits HMG-COA reductase enzyme,

To reduce LDL cholesterol, apolipoprotein beta and triglycerides

Abdominal pain Constipation Flatulence Insomnia Headache Rashes Dizziness Muscle cramps

Hypersensitivity to any component of the preparations

Assess nutrition: fat , protein, carbohydrates; nutritional analysis should be completed by dietitian before treatment is initiated

Monitor creatinine phophokinase levels due to possibility of myopathy; serum cholesterol

Simvastatin Brand Name:

Altovast Route and Frequency: Oral Od Dose:

Children and lactation Active liver disease Unexplained persistent elevations of serum transaminases

To increase HDL cholesterol in the treatment of hyperlipidaemias

which reduces cholesterol production

Monitor triglycerides, cholesterol baseline and throughout treatment

Coronary heart disease

Assess liver function tests prior to therapy and periodically thereafter Evaluate therapeutic response and adverse reactions on a regular basis

40 mg

Assess

knowledge or teach patient proper use

Nursing Name of Drug Generic Name: Imidapril Brand Name: Classification Indications Cardiovascular drugs Treatment of antihypertensive Action -inhibits angiotensin converting enzyme; Route and Frequency: Oral OD Dose: reduction of angiotensin II resulting in dilation of peripheral vessels and reduction of vascular resistance hypertension Side Effects Dry cough Vascor Headache Rash Palpitation Fatigue Discomfort in the throat Contraindications Patients with known hypersensitivity to angiotensin converting enzyme inhibitors or with history of angioneorotic edema Pregnancy and lactation Responsibilities Establish baselines in renal, liver function tests before therapy Check for edema Asses for patient allergic reactions Advise patient to avoid potassium, salt substitutes Teach patient how to take Bp

Monitoring Parameters Monitor blood studies Monitor bp, orthostatic hypotension Monitor electrolytes during the firs 2 weeks of therapy Monitor renal studies and symptoms

50 mg

and normal readings for age group

Nursing Name of Drug Generic Name: Clonidine Brand Name: Action -stimulates central Route and Frequency: Oral OD Dose: alpha adrenergic receptors to inhibit sympathetic cardioaccelareators and vasoconstrictor centers Classification Cardiovascular drugs Centrally-acting drugs Indications Management of all grades of hypertension with the exception of HPN due to phaeochromooyto ma Prophylactic treatment of migraine or recurrent vascular treatment of Side Effects Local skin irritation Drowsiness Dry mouth Headache Fatigue Anorexia Anxiety Contraindications Responsibilities Hypersensitivity to Assess pain, clonidine Sick sinus syndrome location, intensity, character, alleviating, aggravation factors, baseline and frequency Perform blood studies, neorophils, decreased platelets Perform renal

Monitoring Parameters Monitor baselines for renal, liver function test before therapy begins Monitor BP, standing, sitting, supine, mental status, and heart rate.

Catapres

75 mcg

migraine For relief of cancer pain

studies Assess Bp and apical pulse before initial dose Note allergic reactions

NAME OF DRUG Generic Name: Ranitidine Brand Name: Zantac

CLASSIFICATION Gastrointestinal / hepatobiliray Drugs H2 Receptor Antagonists

INDICATIONS Used in management of gastrointestinal (GI) disorders. Prophylaxis of GI hemorrhage from stress ulceration and in patients at risk of developing acid aspiration during general

SIDE EFFECTS Bradycardia Headache Fatigue Depression

CONTRAINDICATIONS Hypersensitivity History of acute porphyria Long-term therapy

NURSING RESPONSIBILITIES Use caution in presence of renal or hepatic impairment. Assess for potential for interactions with other pharmacological agents patient may be taking. Evaluate results of

MONITORING PARAMETERS Monitor AST, ALT, Serum creatinine, signs and symptoms of peptic ulcer disease, occult blood with GI bleeding. Monitor renal function to correct dos.

Mechanism of Route: I.V Frequency: q 12 Action: Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid

Rashes Constipation

Dose: 50 mg

secretion.

anesthesia.

laboratory tests, therapeutic effectiveness.