NURSING CARE PLAN

● POTENTIAL

IMPLEMENTATION
ASSESSMENT
PLANNING Rationale/Justifications
PROBLEM LIST (cues &
DAT NURSING (objectives-long (Nursing Theories of EVALUATIO
(according to evidences/
E DIAGNOSIS term Care, Developmental N
priority) objective & Nursing Interventions References
& short term) stage, tasks, Principles,
subjective)
EBP, Standards of
Nursing Practice)
04/12/ Maslow’s first tier Subjective: Risk for Injury related After 1-2 days of INDEPENDENT INDEPENDENT NANDA After 2 days of
2021 of physiological to Internal factor of nursing intervention, 14th Edition nursing
needs • altered neurologic the patient will: by: intervention, the
• Assess neurologic • Provides information Marilynn E.
regulatory function. patient has:
Maslow’s second Objective: status to include VS that offers clues to Doenges
tier of safety pattern, changes in possible change in Mary
Short term: consciousness, intracranial pressure
•Tonic-clonic Frances
behavior patterns and caused by inflammation Short term:
Maslow’s third seizure Moorhouse
tier of belonging pupillary/ocular of the brain and Alice C.
• Verbalize responses appropriate associated edema. Murr
Maslow’s fourth understanding of for age. pg.479-485 • Verbalized
•High-grade fever
tier of self-worth individual factors understanding
that contribute to of individual
Maslow’s fifth tier possibility of injury factors that
•Headache •Attach cardiac and
of achieving •decrease pulse and contribute to
respiratory monitors to
potential respirations, widen the possibility of
assess for bradycardia
Long Term: pulse pressure with pulse injury
and hypoxia.
becoming irregular and
respirations rapid and
• Be free of injury shallow as ICP Long Term:
• Explain causes of
progresses and the body
increased ICP and
attempts to decrease
• Demonstrate importance of blood flow to the brain. • Be free of
behaviors, lifestyle preventing any further injury
changes to reduce increases in ICP.
risk factors and
protect self from •Allows for • Demonstrated
injury understanding of behaviors,
•Provide a quiet
increased ICP and life- lifestyle
environment free from
threatening nature of changes to
bright lighting,
• Modify such a complication. reduce risk
minimize gentle
environment as factors and
handling and care allow
indicated to enhance protect self
for rest periods between
safety •Promotes comfort and from injury
care or procedures,
rest and reduces
restrict visiting if
irritability.
irritable.
• Modified
environment as
DEPENDENT
indicated to
•Manages existing enhance safety
DEPENDENT
infection and prevents
•Administer antibiotics further spread of
as prescribed infection (action of drug).
(specify) as soon as
ordered based on
analysis of CSF, throat COLLABORATIVE
cultures.
•To maintain a patent
COLLABORATIVE airway and to promote
patient’s safety during
•During seizure, turn the seizure.
patient’s head to the
side, and suction the
airway if needed. Do
not leave the patient.
Ask for another member
of staff for help as
needed.