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Systems Plus College Foundation Balibago, Angeles City

Nursing Care Plan


Student Nurse: Buenafe, Ma.Cresencia S. Yr./Level: BSN Level III Date: Sep. 10, 2012 Problem: Hyperthermia Assessment Nursing Scientific Diagnosis Explanation Hyperthermia Bleeding or edema Subjective: related to edema of the hypothalamus (none) Objective:
Difficulty swallowing Changes in pupillary reactions Altered mental status Slurred speech w/ muscle strength of grade 3 w/ GCS of 8 w/ Capillary refill time of 3 seconds of the hypothalamus as evidence by can lead to ischemia of the thermoregulatory center of the brain which can lead to hyperthermia (Black and Hawk:2005:2126)

Patient Name: Mr. A Medical Diagnosis: Cerebrovascular Accident Age: 90 Sex: Male objectives
After 1 hour of nursing interventions the patients temperature will decrease to normal temperature of 0 37.5 C from the previous temperature of 0 38.4 C 1.

Nursing Interventions
Take temperature every 1-4 hour.

Rationale
1. To obtain an accurate core temperature.(Ignata vacious:2006:516) 2. Non pharmacologic measure lowers body temperature and promotes comfort. Tepid water is used in sponging because cold water increases shivering. (Sparks and Taylor:2005:148) 3. To evaluate effectiveness of interventions and monitor for complications. (Sparks and

Expected Outcome
What was the temperature?

2.

Provide non pharmacological measures to reduce fever such as sponge bath with tepid water

Did the patient feel comfortable?

3.

Monitor Vital Signs every hour

What are the Vital Signs?

w/ Vital Signs of 4. Temp: 38.4 C BP : 90/60 mmHg PR: 73 cpm RR: 10 bpm
0

Taylor:2005:149) Increase Fluid intake up to 70ml/hr unless contraindicated. Monitor Input and output every hour. 4. Insensible fluid loss increased by 0 10% for every 1.8 F increase in temperature. Patient must increase fluid intake to avoid fluid dehydration. (Sparks and Taylor:200:148) 5. Paracetamol produces antipyresis by an action on the hypothalamus; heat dissipation is increased as a result of vasodilation and increased peripheral blood flow. What was the total Input and output?

5.

Administer Paracetamol 300mg/IV every 6 hours PRN

Did the patients temperature improved?

Systems Plus College Foundation Balibago, Angeles City

Nursing Care Plan Student Nurse: Buenafe, Ma.Cresencia S. Yr./Level: BSN Level III Date: Sep. 10, 2012 Problem: Ineffective Cerebral Tissue Perfusion Assessment Subjective: (none) Objective:
Difficulty swallowing Changes in pupillary reactions Altered mental status Slurred speech w/ muscle strength of grade 3 w/ GCS of 8 w/ Capillary refill time of 3 seconds

Patient Name: Mr. A Medical Diagnosis: Cerebrovascular Accident Age: 90 Sex: Male

Nursing Diagnosis
Ineffective cerebral tissue perfusion r/t interruption of blood flow secondary to CVA

Scientific Explanation
The presence of partial blockage of the blood vessel can be multifactorial. These can be due to vasoconstriction, platelet adherence on rough surface, fat accumulation and therefore decreases elasticity of vessel wall leading to alteration of blood perfusion with the initiation of the clotting sequence. This may later lead to the development of thrombus which can be loosened and dislodged in some

Planning
After 3 hours of Nursing Interventions, the patient will be able to display decrease signs of ineffective tissue perfusion as evidence by good capillary refill, pink conjunctiva and gradual improvement of vital signs. 1. 2.

Interventions
Establish rapport Monitor vital signs every 1 hour 1.

Rationale
To promote cooperation To have a baseline data, assess changes in neurologic status To determine blood circulation

Evaluation
Was the client cooperative? What are the Vital signs?

2.

3.

Check capillary refill and conjunctiva for paleness Elevate head of 0 bed to 30 (midline or neutral position) Keep environment quiet. Space

3.

What was the Capillary refill time?

4.

4.

To promote circulation/Venou s drainage (Smeltzer;2004:5 39) These measures reduce

Did it promote circulation?

5.

5.

Is the patient well rested?

w/ Vital Signs of Temp: 35.2 C BP : 90/60 mmHg PR: 73 cpm RR: 10 bpm
0

areas of the brain such as mid cerebral carotid artery that may lead to alteration of blood perfusion and further develop to cerebral infarct.

nursing actions 6. Avoid neck flexion and extreme hip/knee extension Provide and maintain oxygen via nasal cannula at @ 2 Lpm as ordered Perform GCS monitoring every hour as ordered

intracranial pressures. 6. To avoid obstruction of arterial and venous blood flow Reduces hypoxia w/c can cause vasodilation and increase pressure/edema formation To detect changes indicative of worsening or improving condition To promote wellness What are the activities done

7.

7.

What is the RR?

8.

8.

What is the GCS?

9.

Administer Citicholine 75 mg/tab @8am, Fluimicil/tab @ 8am, NaCl /tab @ 8am, and Vestar 35mg/tab @8am as ordered

9.

Did it promote wellness?