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Nursing Care Plan: Name: DRT Age: 67 Diagnosis: Cva 2° To HPN

A 67-year-old male patient presented with a diagnosis of cerebral vascular accident secondary to high blood pressure. He complained of severe headache when going to the bathroom. His vital signs and physical exam showed elevated blood pressure, increased heart rate, flushing of skin, altered mental status, speech abnormalities, and decreased sensation in the lower extremities. The nursing care plan aimed to reduce his headache level from 6/10 to 3/10 in 6 hours and be pain free within 3 days through interventions like pain assessment, positioning, quiet environment, comfort measures, relaxation techniques, diversional activities, avoidance of triggers, and pain medication administration.

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Kristina Marie Parulan Rn
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4K views3 pages

Nursing Care Plan: Name: DRT Age: 67 Diagnosis: Cva 2° To HPN

A 67-year-old male patient presented with a diagnosis of cerebral vascular accident secondary to high blood pressure. He complained of severe headache when going to the bathroom. His vital signs and physical exam showed elevated blood pressure, increased heart rate, flushing of skin, altered mental status, speech abnormalities, and decreased sensation in the lower extremities. The nursing care plan aimed to reduce his headache level from 6/10 to 3/10 in 6 hours and be pain free within 3 days through interventions like pain assessment, positioning, quiet environment, comfort measures, relaxation techniques, diversional activities, avoidance of triggers, and pain medication administration.

Uploaded by

Kristina Marie Parulan Rn
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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NAME: DRT AGE: 67 DIAGNOSIS: CVA 2° to HPN NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS

S- “Sumasakit ang Acute Pain STG: 1.Perform pain -to determine the STG:
ulo ko kapag related to After 6 hours of assessment(location,duration,intensity,quality etiology of the Goal met,After 6
nagpupunta akong increased Nursing and characteristic) condition hours of Nursing
palikuran “, as Intracranial Intervention, the 2.Postion the client: HOB elevated with body -to decrease ICP Intervention, the
verbalized by the Pressure client’s level of in central position client’s level of
client. asmanifested by pain from 6/10 will 3. Provide quiet,calm and relaxing -to minimize pain pain from 6/10 was
flushing of skin. decrease into environment. decreased into
Pain Level= 6 3/10 4.Provide comfort measures -to minimize pain 3/10
5.Instruct the client to relax -to minimize pain
O- VS as follows: 6.Encourage diversional activities -to minimize pain
BP- 140/90 LTG: 7.Instuct the client to avoid going to -to decrease ICP LTG:
mmHg After 3 days of bathroom Goal met.After 3
T- 36.5°C Nursing 8.Instruct the client to avoid activities that -to decrease ICP days of Nursing
PR- 68 bpm Intervention, the may contribute to Increase Intracranial Intervention, the
RR- 19 cpm client will be free pressure client is free from
-Flushing of skin from pain 9.Administer pain medication as ordered by -to relieve or pain
-altered mental the physician control pain
status
-speech
abnormalities
-decreased
sensation on lower
extremities

NAME: DRT AGE: 67 DIAGNOSIS: CVA 2° to HPN NURSING CARE PLAN


ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

S- “Sumasakit ang Acute Pain STG: 1.Perform pain -to determine the STG:
ulo ko kapag related to After 6 hours of assessment(location,duration,intensity,quality etiology of the Goal met,After 6
nagpupunta akong increased Nursing and characteristic) condition hours of Nursing
palikuran “, as Intracranial Intervention, the 2.Postion the client: HOB elevated with body -to decrease ICP Intervention, the
verbalized by the Pressure client’s level of in central position client’s level of
client. asmanifested by pain from 6/10 will 3. Provide quiet,calm and relaxing -to minimize pain pain from 6/10 was
flushing of skin. decrease into environment. decreased into
Pain Level= 6 3/10 4.Provide comfort measures -to minimize pain 3/10
5.Instruct the client to relax -to minimize pain
O- VS as follows: 6.Encourage diversional activities -to minimize pain
BP- 140/90 LTG: 7.Instuct the client to avoid going to -to decrease ICP LTG:
mmHg After 3 days of bathroom Goal met.After 3
T- 36.5°C Nursing 8.Instruct the client to avoid activities that -to decrease ICP days of Nursing
PR- 68 bpm Intervention, the may contribute to Increase Intracranial Intervention, the
RR- 19 cpm client will be free pressure client is free from
-Flushing of skin from pain 9.Administer pain medication as ordered by -to relieve or pain
-altered mental the physician control pain
status
-speech
abnormalities
-decreased
sensation on lower
extremities

NAME: DRT AGE: 67 DIAGNOSIS: CVA 2° to HPN NURSING CARE PLAN


ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

S- “Sumasakit ang Acute Pain STG: 1.Perform pain -to determine the STG:
ulo ko kapag related to After 6 hours of assessment(location,duration,intensity,quality etiology of the Goal met,After 6
nagpupunta akong increased Nursing and characteristic) condition hours of Nursing
palikuran “, as Intracranial Intervention, the 2.Postion the client: HOB elevated with body -to decrease ICP Intervention, the
verbalized by the Pressure client’s level of in central position client’s level of
client. asmanifested by pain from 6/10 will 3. Provide quiet,calm and relaxing -to minimize pain pain from 6/10 was
flushing of skin. decrease into environment. decreased into
Pain Level= 6 3/10 4.Provide comfort measures -to minimize pain 3/10
5.Instruct the client to relax -to minimize pain
O- VS as follows: 6.Encourage diversional activities -to minimize pain
BP- 140/90 LTG: 7.Instuct the client to avoid going to -to decrease ICP LTG:
mmHg After 3 days of bathroom Goal met.After 3
T- 36.5°C Nursing 8.Instruct the client to avoid activities that -to decrease ICP days of Nursing
PR- 68 bpm Intervention, the may contribute to Increase Intracranial Intervention, the
RR- 19 cpm client will be free pressure client is free from
-Flushing of skin from pain 9.Administer pain medication as ordered by -to relieve or pain
-altered mental the physician control pain
status
-speech
abnormalities
-decreased
sensation on lower
extremities

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