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Vii. NCP

After 8 hours of nursing intervention, the patient's skin integrity and cerebral function are expected to improve. The nursing care plan involves assessing the patient's skin and neurological status regularly to monitor for impairment. Interventions include repositioning the patient every 2 hours to reduce pressure, administering medications to increase blood flow and control seizures, and monitoring vital signs to ensure adequate tissue perfusion. The goals are to maintain intact skin with no redness or sores, and to see an improved or usual mental status indicating better cerebral perfusion.

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626 views4 pages

Vii. NCP

After 8 hours of nursing intervention, the patient's skin integrity and cerebral function are expected to improve. The nursing care plan involves assessing the patient's skin and neurological status regularly to monitor for impairment. Interventions include repositioning the patient every 2 hours to reduce pressure, administering medications to increase blood flow and control seizures, and monitoring vital signs to ensure adequate tissue perfusion. The goals are to maintain intact skin with no redness or sores, and to see an improved or usual mental status indicating better cerebral perfusion.

Uploaded by

maria
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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VII.

Nursing Care Plan


Assessment
Risk Factors:

Nursing Diagnosis

Risk for impaired


skin integrity related
Patient
is to
admitted in ICU perceptual/cognitive
for more than 1 impairment
week.
Immobility, which
physical
leads to pressure,
immobility:(+)
shear,
and friction,
right
sided
is the factor most
weakness
likely to put an
limited range of
individual at risk for
motion;
altered skin integrity.
decreased
Advanced age; and
muscle
the normal loss of
strength/control
elasticity;
GCS- 8
inadequate
nutrition,
(E=2, V=1, M=5)
environmental
moisture, especially
from incontinence;
and vascular
insufficiency
potentiate the
effects of pressure
and hasten the
development of skin
breakdown.
(http://www1.us.else

Planning

Intervention

Rationale

After 8 hours of
nursing
intervention, the
patients
skin
integrity will be
maintained.

Assess
general
condition of skin.
Inspect
skin
regularly,
particularly
over
bony
prominences.

Pressure
points
over
bony
prominences
are
most at risk for
decreased
perfusion.

Assess
patient's Immobility is the
ability to move by greatest risk factor
using
Glasgow in skin breakdown
coma scale.
Assess for edema.

Change positions
at least every 2
hours
(supine,
side lying) and
possibly
more
often if placed on
affected side.
Use of lift sheets
to move patient in

Skin
stretched
tautly
over
edematous tissue
is
at
risk
for
impairment.
Reduces risk of
tissue
injury.
Affected side has
poorer circulation
and
reduced
sensation and is
more predisposed
to skin breakdown.

Expected
Outcomes
After 8 hours of
nursing
intervention, the
patients skin will
remain intact, as
evidenced by no
redness
over
bony
prominences and
presence of bed
sores.

vierhealth.com/)

bed

Assessment

Nursing Diagnosis

Planning

Altered level of
consciousness
GCS- 7
(E=1 V=1, M=5)
Pupillary size of
2mm, NRTL

Changes in
Vital signs
Changes
in
motor
or
sensory
responses
CT Scan Report
of the Head:
Acute infarct,left
MCA
(left
frontotemporoparietal
region
extending to the
left
insular
cortext)

Ineffective Cerebral
Tissue Perfusion
related to
interruption of blood
flow

After 8 hours of
nursing
intervention, the
patient will be
noted
for
increased
cerebral function
as evidenced by
a
usual
or
improved mental
status.

Cerebrovascular
disorders is an
umbrella term that
refers to a functional
abnormality of the
central nervous
system (CNS) that
occurs when the
normal blood supply
to the brain is
disrupted. In
ischemic stroke,
significant
hypoperfusion occur
because of vascular
occlusion. (Smeltzer
et. al. [2010].

It reduces
shearing forces on
the skin.
Rationale

Intervention
Monitor
document
neurological
frequently
compare
baseline.

and
status
and
with

Evaluate
pupils,
noting size, shape,
equality, and light
reactivity.

Assesses trends in
LOC and potential for
increased ICP and is
useful in determining
location, extent, and
progression
or
resolution of CNS
damage
Pupil reactions are
regulated
by
the
oculomotor
(III)
cranial nerve and are
useful in determining
whether
the
brainstem is intact.
Pupil
size
and
equality
is
determined
by
balance
between
parasympathetic and
sympathetic
enervation.
Response to light
reflects
combined
function of the optic
(II) and oculomotor
(III) cranial nerves.

Expected
Outcomes
After 8 hours of
nursing
intervention, the
patient will be
noted for having
an
improved
cerebral
tissue
perfusion
as
evidenced
by
usual or improved
mental status.

Continuation
Assessment

Nursing Diagnosis
.

Planning

Intervention

Rationale

Monitor vital signs.

Stable
blood
pressure
is
necessary
to
maintain
adequate
tissue
perfusion,
especially
cerebral
perfusion.

Administer
medications as
ordered:
Citicholine 1 gm IV
every 12 hours

Citicoline increases
blood flow and O2
consumption in the
brain. It is also
involved in the
biosynthesis of
lecithin.

Isoptin

A calcium channel
blocker that inhibits
calcium blocker that
inhibits calcium ion
influx across cardiac
and smooth-muscle
cells, thus decreasing
myocardial
contractility and

40mg 1 tablet twice


a day

Expected
Outcomes

oxygen demand; it
also dilates
coronary arteries and
arterioles.
Dilantin
100mg 1 capsule
every 8hours

May be used to
control seizures and
for sedative action

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