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The nursing care plan document outlines goals, interventions, and evaluations for a patient with issues related to hypoxia, hypertension, and risk for brain injury over multiple shifts, with goals of stabilizing vital signs, managing conditions through medication and lifestyle changes, and ensuring the patient understands factors that contribute to their health issues. Nursing interventions include monitoring respiratory rate, blood pressure, and other vital signs; providing treatments, education, and rest; and assessing whether goals such as normalizing breathing and reducing blood pressure are achieved.
The nursing care plan document outlines goals, interventions, and evaluations for a patient with issues related to hypoxia, hypertension, and risk for brain injury over multiple shifts, with goals of stabilizing vital signs, managing conditions through medication and lifestyle changes, and ensuring the patient understands factors that contribute to their health issues. Nursing interventions include monitoring respiratory rate, blood pressure, and other vital signs; providing treatments, education, and rest; and assessing whether goals such as normalizing breathing and reducing blood pressure are achieved.
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The nursing care plan document outlines goals, interventions, and evaluations for a patient with issues related to hypoxia, hypertension, and risk for brain injury over multiple shifts, with goals of stabilizing vital signs, managing conditions through medication and lifestyle changes, and ensuring the patient understands factors that contribute to their health issues. Nursing interventions include monitoring respiratory rate, blood pressure, and other vital signs; providing treatments, education, and rest; and assessing whether goals such as normalizing breathing and reducing blood pressure are achieved.
Copyright:
Attribution Non-Commercial (BY-NC)
Verfügbare Formate
Als DOCX, PDF, TXT herunterladen oder online auf Scribd lesen
G CE AN LE ON INTERVENTI DIAGNO ON SIS No Ineffective Hypoxia is Following ♦ Assessed ♦ Provide At the end of Subjectiv airway a an 8-hr respiratory s a basis the shift, the e Cues clearance pathologic nursing client was related to al interventio rate. for able to hypoxia. condition n, the evaluati display Objective in which client will ng patency of : the body be able to: airway as adequac as a whole manifested Dyspn (generalize Normal y of by: ea; use d hypoxia) breathin ♦ Noted chest ventilati Client’s or a region g movement; of on. of the respirator access pattern: use of body y rate is ory (tissue RR = accessory ♦ Use of within hyoxia) is 12-20 muscles muscle accessor normal deprived s for cpm during of y range: respira adequate respiration. muscles RR-18 oxygen tion: of bpm. supply. elevate respirati d ♦ Auscultated on may should breath occur in ers. sounds; respons noted areas e to Increa with ineffecti se in presence of ve respira adventitiou ventilati tory s sounds. on. rate: RR-25 cpm ♦ Crackle s indicate accumul ation of secretio ns and inability to clear airways.
E AN ALE ION DIAGNOSI INTERVEN S TION No Ineffective Increased After 4 > Monitored > To > After 4 Subjective cerebral cardiac hours of blood know the hours of Cues tissue output that nursing pressure base line nursing perfusion injures the interventio every 4hours. of BP > intervention related to endothelial n the pt > Instructed Sodium the increased cells of the blood to have tends to bepatient’s intracranial arteries and pressure enough rest excreted atblood Objective: pressure the action of will on semi a faster pressure and prostaglandi decrease fowlers rate. was PR = 85 vasoconstri ns. from 160/ position. > decreased bpm ction of Vasoconstri 100mmHg Instructed to from RR = 30 blood ction occurs to eat low fat > To 160/100mm bpm vessels and blood 120/80mm and low salt reduce Hg to pressure Hg. diet. > edema that 140/90mm 160/100m increases. Administered may Hg. mHg anti- activate hypertensive renin drug as angiotensi ordered. n- aldosteron e system. > To control the BP and to avoid other complicati ons.
CE AN LE ON DIAGNO INTERVENTI SIS ON No Risk for Brain After 3 Monitor •To assess After 3 hours Subjecti injury damage or hours of peripheral baseline of nursing ve Cues related to "brain nursing pulses and data intervention, brain injury" interventio vital signs, the client damage. (BI); n, the client especially the •To assist verbalized means the will be able heart rate client to understandin destruction to verbalize every hour to reduce or g of Objectiv or understandi every four correct individual e: degenerati ng of hours individual factors that on of brain individual depending on risk factor. contribute to T: 36.7 cells, often factors that the client’s possibility of PR: 65 with an contribute condition. injury and bpmRR: implication to take steps to that the possibility • correct 18 cpmBP: loss is of injury Provide situations.Go 120/70 significant and take information al was met mmHg in terms of steps to regarding functionin correct disease/conditi g or situations on that may conscious result in experience increased risk . It is a of injury. common and very broad in scope, such that in medicine a vast range of specific diagnoses exist. Brain injuries occur due to a wide range of internal and external factors. A common category with the greatest number of injuries is traumatic brain injury (TBI) following physical trauma or head injury from an outside source, and the term acquired brain injury (ABI) is used in appropriate circles, to differentiat e brain injuries occurring after birth from injury due to a disorder or congential malady.
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