NURSING CARE PLAN

*Introduction

Yianah: Good morning to our clinical instructor, Ma’am Dubria, to our PCI’s, and Good Morning
everyone. Before we proceed to our Case Presentation, allow us to introduce ourselves. We are
from BSN-2N, Group 2, Subgroup 1 - Group 1. I am Yianah Maurisse Gementiza and together
with my groupmates: Mr.Ditchon, Mr. Hadjes, Ms. Hene, Mr. Iwao, Ms. Java, Ms. Lara, Ms.
Licatan, We will be having a discussion of our Case Study Presentation about the scenario that
was given to us a few weeks ago.

First and foremost, the content of our NCP is based on the outstanding efforts and hardwork of
one of our groupmates, Ms. Java and Mr. Iwao (char!)

*Flow of the Presentation

JM: This will be the flow of our presentation for you to be guided. (ibasa lang yung sa ppt)

*Case Scenario

Ron: As we all know, in the Nursing Process, we need to follow certain steps in order for us to
deliver holistic, patient-focused care. We already know the acronym ADPIE (assessment,
diagnosis, planning, implementation, and evaluation). So, let us start first on the Assessment
part in which we will be presenting the following:

*ibasa lang sa ppt <333

*Patient’s Diagnosis:

Trishia: Upon the said assessment, the patient was diagnosed with CerebroVascular accident.
On the next following slides, we will be having a brief discussion of this particular ailment.

*ibasa lang sa ppt ang meaning and symptoms <333

*NCP

CL A RK: Let us move on and discuss the Nursing Care Plan. Once again, the making of the
NCP is important because it assists in developing and executing a sound action plan by clearly
defining the rules and the nurse's role in patient care.

So, this was implemented on August 26, 2022 at 7 AM during the 7-3 shift. Based on the data
we have collected and observed, these are the following cues.
For the subjective cues:
● Patient is noted to have the following:
a. Weakness and numbness in the right upper and lower extremities after
sustaining a fall in the bathroom, as verbalized by the wife.
b. According to the wife, Patient A was not able to defecate for 4 days.

For the objective cues, this includes the following:

● Unequal facial asymmetry
● Slurring of speech
● Crackles were noted on both lung fields raise right arm upon instruction with weakness
right foot.
● Pain scale is 8/10 in Wong Baker Pain Assessment Tool with facial grimacing noted
● CRT is 3 seconds with bipedal edema; Pitting edema on extremities
● Patient is warm to touch
● Amber-colored urine output
● Patient’s vital signs are the following:
- Temperature: 38.5 C
- Pulse Rate: 112 bpm
- Respiratory Rate: 22 cpm
- BP: 180/100 mmHg
- O2 Sat: 92%

Yessady: To continue, the patient also had a neurological assessment using the Glasgow
Coma Scale or GCS. Here are the results:
● Eye Opening: (3) To Speech
● Best Verbal Response: (4) Confused
● Best Motor Response: (6) Obeys Command
● Pupil Size: 3mm (OD), 4mm (OS); brisk

Over-all, the result of his GCS is equivalent to 13

In addition, the following contraptions are attached:

1. IVF PNSS 1L running at KVO rate, with side drip of Nicardipine running at 100ml/hr.
Rate
2. NGT Fr. 16 at left nares, distal end closed for feeding and medications
3. Indwelling FC Fr. 14 draining to urobag

*Need
France: In accordance to the Gordon’s 11 Functional Pattern which is used to provide a more
comprehensive nursing assessment of the patient, we chose the Cognitive/Perceptual
Pattern

- To define this functional pattern, The cognitive-perceptual health pattern is concerned

with how people gather information from their surroundings as well as how they
understand and use it.
- Reason: huhu palagay ano reason why niyo gichoose ;((

*Diagnosis:

AJ: For our nursing diagnosis, to give you an overview of its definition, it is a clinical judgment
regarding an individual's, family's, or community's responses to real or potential health issues or
life processes. Therefore, the diagnosis that we have chosen is…

● Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to

hypertension as evidenced by aching pain with a pain scale of 8/10 in Wong Baker Pain
Assessment Tool and change in motor function.
● R: sis ikaw na bahala magsabi <33

● Add info langzxs: In simple words, Cerebral tissue perfusion refers to the blood flow in
the brain and it is necessary in order for the brain to function. When ineffective cerebral
perfusion occurs, less glucose and oxygen reach the brain and can result in brain
damage and neurological issues
● Explain Reason why niyo gichoose

*Outcome

JM: Let us now discuss our desired Outcomes/Goals. Basically, this is characterized as a
measurable state, behavior, or perception of a person, family, or community that is assessed
along a continuum in response to nursing interventions. The following nursing outcomes that we
wish to achieve by the patient are the following:

*ibasa lang sa ppt <333

*Nursing Interventions/Implementation
Yianah: Let us now discuss our Nursing Interventions which are the steps a nurse takes to
carry out their patient care plan, which may include any treatments, procedures, or learning
opportunities aimed at enhancing the patient's comfort and health. For this case scenario, we
implemented 13 Nursing Interventions and with its Nursing Implementation, which is putting the
plan of care into practice, it’s been categorized to high priority, medium priority, and least
priority.

● Number 1: Determine factors related to individual situation, decreased cerebral

perfusion and potential for ICP.
● Rationale: Different factors influence the choice of interventions. This is also to identify
clients at higher risk for decreased cerebral perfusion related to bleeding and/or
coagulation problems.

Yianah:
● Number 2: Monitor and document neurological status frequently.
● Rationale: Determines the location, magnitude, and progression or resolution of CNS
injury. Also, it evaluates trends in LOC and possibility for increased ICP.

Trishia:
● Number 3: Monitor and record vital signs noting hypertension or hypotension, heart rate,
pupillary reaction and respirations.
● Rationale: Irregularities in the signs noted are indications of problems or complications
of the brain functions. Additionally, fluctuations and changes in pressure may be brought
upon by cerebral injury hence hypertension or hypotension may have been a triggering
factor

Trishia:
● Number 4: Determine the presence of visual, sensory or motor change, headache,
dizziness, altered mental status, personality changes.
● Rationale: These alterations point to potential safety issues and affect the nursing
intervention decision.

CL A RK:
● Number 5: Position client with head slightly elevated and in neutral position
● Rationale: This encourages venous outflow, which lowers arterial pressure and might
enhance cerebral perfusion and circulation

CL A RK:
● Number 6: Avoid actions that could cause a rise in ICP, such as coughing, vomiting,
straining at stool, neck in flexion, head flat, or bearing down.
● Rationale: These will lessen cerebral blood flow even further.

Yessady:
 ● Number 7: Administer medications like antihypertensives,diuretics and anticonvulsants
as ordered.
● Rationale: These medications may be used to reduce the risk of seizure which may
come from cerebral edema

Yessady:
● Number 8: Control environmental temperature as necessary. Perform a tepid sponge
bath when fever occurs.
● Rationale: Fever could indicate a symptom of damage to hypothalamus. With this, ICP
might be further elevated by fever and shivering.

Ron:
● Number 9: Instruct to prevent straining at stool or holding of breath.
● Rationale: Valsalva’s maneuver raises ICP and exacerbates risk of bleeding.

Ron:
● Number 10: Maintain bedrest, provide a calm setting, and limit guests or activities as
indicated. Rest periods should be provided in between care tasks to shorten procedure
times.
● R:Constant stimulation can raise ICP. In the event of a hemorrhagic stroke, absolute
silence and rest may be required to prevent further bleeding.

JM:
● Number 11: Provide instructions of relaxation techniques including meditating and
listening to music.
● R: Stress can further increase ICP and promoting relaxation can prevent increase of
ICP.

● Number 12: Administer supplemental oxygen as needed

● R:This promotes oxygenation and guards against problems brought on by inadequate
brain tissue perfusion.

● Number 13: Have an accurate intake-output count and monitor laboratory studies
● R: This provides information about the effectiveness of the drugs used to treat the
condition.
*Evaluation (give minimal explanation)

France: Let’s proceed to the last part of our Nursing Care Process which is the Evaluation.
Basically, it is a deliberate, continuing action that measures the client's success in
accomplishing objectives or desired results as well as the efficiency of the nursing care plan
(NCP).

So, After 8 hours of rendering therapeutic nursing care, goals were completely met.

The patient specifically:

a. Maintained vital signs that are within the normal range, especially blood pressure.
b. Had improved cerebral tissue perfusion as evidenced by normal capillary refill time.

AJ: *continuation*

c. Had improvement in terms of movement

d. Displayed no signs of increased ICP.
e. Verbalized understanding of risk factors or conditions, therapy regimens, side effects of
medications, and when to contact healthcare providers.

*ikaw na magconclude at mag goodbye sis

ALWAYS REMEMBER THAT AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE

#potanginaNCP <33
Yianah:

1. Cues
2. Need
- With this Gordon’s Functional Pattern, we want to look at the patient
holistically. Since the patient is taking maintenance medication for his
hypertension, in order not to put strain on the heart, damages blood
vessels in the kidneys and damages the retina, this needs to be controlled.
- There were no mentioned habits or activities of daily life and there were no
recent checkups mentioned, so this must be put into focus. We also need
to focus on the patient’s perception of his health since with his age and his
current condition, it is a big factor that contributes to his well being
3. Diagnosis
- To make it more simpler, Cerebral tissue perfusion refers to the blood flow
in the brain and it is necessary in order for the brain to function. When
ineffective cerebral perfusion occurs, less glucose and oxygen reach the
brain and can result in brain damage and neurological issues
- So we chose the risk nursing diagnosis which is a clinical judgment
concerning the vulnerability of the patient to develop a disease/illness

JM:
1. Outcome

2. Interventions 1-5 + Implementation

- For our nursing interventions and its implementation, we have already put
it into sequence from high priority to low priority

Farrah
1. Interventions 6-10 + Implementation
2. EvaluationQ
*Intro for PA

Yianah:

A. Biographical Data
- Room 123 Bed 1, Pediatric Ward, Patient B, 2 years old, Male was admitted

B. Admission History
- The patient had no history of previous hospitalization.

C. History of present illness

- For the past 3 days, Patient B was admitted due to fever, diarrhea and vomiting.
 D. Past health illness
- When the patient was 6 months old he had urticaria, a skin condition that causes
a raised, itchy rash. The disease was then treated by steroids to reduce the
symptoms faster

E. Family health story

- The patient's mother did not mention any family health history that may have
caused the patient’s present illness.

Farrah:

F. Gordon’s Functional Health Pattern

This is to provide a comprehensive nursing assessment of the patient

I. Health Perception/Health Management Pattern

Patients’ general health hasn't been that good for the past few months because he is
tachypneic but not dyspneic, which has caused rapid breathing since the mother
observed it. Patient b is able to consume 12oz of milk and has a good appetite. The
mother mentioned that he coughed since the client was admitted and his pulse is
kinda weak.

II. Nutritional/Metabolic Pattern

Administration of IVF of D5LR 500 ml running at 120ml/hr rate via the left cephalic
vein and FD 100cc. Patient’s appetite is good and is able to consume 12oz of milk

III. Elimination Pattern

Had a non-projectile whitish-colored vomit; child had a watery stool and defecated 4x
since admission as verbalized by the mother and had a yellowish urine output;
patient’s diaper was changed 2x since 6 am

IV. Activity/Exercise Pattern

The parent did not mention any activity or exercise pattern, although patient B is a
toddler we all know that toddlers are active in any physical activities because it is
where they are more into that kind of age group.
 V. Sleep/Rest Pattern

Sleep/rest pattern was not mentioned by the patient’s mother.

VI. Cognitive/Perceptual Pattern

The patient's hearing is clear in both ears, and there have been no problems since.
The patient may hear both the student nurses' normal tone and their whispering tone
when they examine the ear. As a result, hearing is still viable.

VII. Self-Perception/Self-Concept Pattern

It wasn’t mention during the assessment

VIII. Roles/Relationship Pattern

The patient is a toddler that was assisted and observed by her mother all the time.

For
Sexuality/Reproductive Pattern
Coping/Stress Tolerance Pattern
Values/Beliefs Pattern

These patterns may not apply to patient B because he is in fact a toddler and can not
describe these on his own at this age and the only thing we know is that toddlers at
this age are active in any physical activities that they are more involved in.

JM:
Physical Assessment of Situation
Eyes to Neuro *basahi lang sa ppt*

For the Glasgow Coma Scale the eye opening of the patient responses to speech which is
scored as 3 out of 4 and for verbal and motor response the patient had a perfect score, he is in
response oriented and obeys command during the assessment which gave him an overall score
of 14 out of 15.

General Survey/Conclusion
After gathering all the patient’s data, we have analyzed that the patient’s vital signs are
somewhat abnormal with a higher rate than the normal rate for a toddler. The mother of
the client was concerned with how rapid his breathing patterns are than the normal. The
mother of the clients was questioned using Gordon's 11 Functional Health Pattern to
gather subjective data. Another method of gathering the objective data was doing
Inspection, Palpation, Percussion, and Auscultation on the patient from head to toe.
Upon evaluation, including his musculoskeletal and neurological assessments,
unexpected findings were recorded and seen from head to toe. There is not that much
data gathered from the mother of the patient, but some observations from the mother
that was stated was helpful for us to know other findings about Patient B’s condition.
Normal and abnormal findings were noted and observed from head to toe upon
assessment.

Nevertheless, We were able to complete the thorough exam as intended, and we have
subsequently recognized how important it is to establish a connection with your patient
and the patient's guardian so that they feel at ease answering questions like these and
participating. Additionally, nurses need to have the education necessary to respond to
the patients' questions and give them health advice. In conclusion, physical
examinations would aid student nurses in honing their abilities and make them feel
prepared for real-life settings when they are dispatched to the hospital.