ASSESSMENT NSG.

DIAGNOSIS PLANNING INTERVENIONS RATIONALE EVALUATION

Objectives: Risk for injury At the end of the • Kept padded side • Minimizes injury -Generalized jerking
-Generalized jerking related to episodes nursing rails up with bed should seizures seizures noted
seizure noted lasting of seizures intervention, the in lowest position. occur while the lasting for 21 secs.
for 33 secs. in a patient will be client is in bed. in a minute.
minute protected from • Stayed with the • Promotes client -(+) facial twitching
-(+) facial twitching injury. client during and safety and -GCS-6
-Weak in after seizures. reduces sense of -Maintained client
appearance isolation during safety.
- GCS – 3 event.
• Turned head to • Helps maintain
side. airway.
• Suctioned airway. • Helps maintain
airway.
• Performed • Document
neurologic and postictal state and
vital signs check time /
after seizure. completeness of
recovery to
normal state.
• Administered • Control seizure
medications as activity.
indicated
(Diazepam,
Valproic Acid)
• Monitored CBC, • Identifies factors
electrolytes and that aggravate /
glucose levels. decrease seizure
threshold.
 ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENIONS RATIONALE EVALUATION
Objectives: Ineffective breathing At the end of the • Assessed client’s • For baseline -PR-97 bpm
- RR- 24 bpm pattern related to nursing condition. Note purposes. -RR-26 bpm
-with wheezing neuromuscular intervention, the rate, rhythm, -O2sat- 97%
sound heard on both impairment patient will depth of - Generalized jerkin
lung fields upon secondary to disease maintain effective respiration. seizures noted
auscultation condition respiratory pattern • Noted • Loss of swallow lasting for 21 secs.
-PR- 107 with patent airway. competence of or cough reflex in a minute.
-O2 Sat – 97% gag / swallow may indicate need -(+) facial twitching
-Generalized reflexes for artificial -GCS-6
jerking seizure airway or
noted lasting for 33 intubation
sec in a minute • Monitored ABGs • Determines
-(+) facial twitching and pulse respiratory
-Weak in oxymetry. sufficiency, acid
appearance base balance and
- GCS – 3 therapy needs.
- (+) asthma • Elevated head of • Facilitates lung
- (+) stg. IV bed as permitted, expansion and
Melanoma; position on sides reduces airway
metastasized on as indicated. obstruction.
skeletal and • Placed in lying • Promotes
pulmonary position, flat drainage of
surface; turned secretions and
head to side prevents tongue
during seizure from obstructing
activity. the airway.
• Loosened clothing • Facilitates
from neck, chest breathing and
and abdominal chest expansion.
area.
• Administered • May reduced
supplemental cerebral hypoxia
 oxygen. resulting form
decreased
circulation /
oxygenation
secondary to
vascular spasm
during seizure.
• Intubation and ET • Presence of
tube insertion prolonged apnea
done. postictally may
require ventilator
support.

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENIONS RATIONALE EVALUATION

Objectives: Ineffective cerebral At the end of the • Assessed client’s • For baseline -Seen on
-Weak in tissue perfusion nursing condition purposes. semifowlers
appearance related to intervention, the • Determined •Influences choice position
-on mechanical inadequate oxygen patient will factors related to of intervention. -BP-110-70 mmHg
ventilator support in the brain demonstrate vital individual -PR-97 bpm
-PR-107 bpm signs in the absence situation , cause -RR-26 bpm
-RR-24 bpm of signs of increases for coma / -O2sat- 97%
- BP- 80/80 mmHg ICP. decreased cerebral - Generalized jerkin
-O2 sat- 97% perfusion and seizures noted
-GCS- 3 potential for lasting for 21 secs.
-Generalized jerking increased ICP in a minute.
seizure noted lasting • Monitored • Assesses trends -(+) facial twitching
for 33 sec in a neurologic status and potential for -GCS-6
minute frequently increased ICP and
-(+) facial twitching is useful in
determining the
location, extent
and resolution of
 CNS damage.
• Monitored vital • For baseline
signs. purposes.
• Noted presence or • Altered reflexes
absence of reflect injury at
reflexes. level of midbrain
or brainstem and
have direct
implications for
client safety.
• Monitored intake • Cerebral trauma /
and output. Noted ischemia can
for skin turgor, result in diabetes
status of mucous insipidus or
membrane. syndrome of
inappropriate
antidiuretic
hormones.
• Encourages SO to • Familiar voices of
talk with the the family / SO
client. appear to have
relaxing effect on
many comatose
patients which
can reduce
increased ICP.
• Observed seizure • Seizures can
activity and occur as a result
protected client of cerebral
for injury. irritation, hypoxia
or increased ICP.
• Assessed for • Indicate
nuchal rigidity, meningeal
 twitching, irritation.
increased
restlessness and
onset of seizure
activity.
• Elevated head of • Promotes venous
bed gradually to drainage from
20-30 degrees as head, thereby
tolerated. reducing cerebral
congestion and
increased ICP.
• Administered • Reduces
oxygen via hypoxemia which
mechanical increase cerebral
ventilator. vasodilation and
blood volume,
elevating ICP.
• Initiated cooling •Maybe needed to
measures as regain / maintain
indicated. normal core body
temperature.

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENIONS RATIONALE EVALUATION

Objectives: Impaired tissue At the end of the • Inspected skin. •Provide -Sees SO massaging
-with stg. 2 integrity related to nursing Tissues and opportunity for bony prominences
decubitus ulcer presence of interventions, the mucous early intervention. -
-(+) stg. IV decubitus ulcer patient will membrane
Melanoma; maintain intact skin. routinely.
metastasized on • Assessed • Nutrition can
skeletal and nutritional status prevent nutrition
pulmonary and initiates breakdown and
-with fair skin corrective promote ulcer
turgor measures as healing.
-weak in appearance indicated.
-Generalized jerking • Monitored HcT • Anemia,
seizure noted lasting and blood glucose dehydration and
for 33 sec in a levels. elevated sugar
minute levels are factors
in skin
breakdown and
can impair
healing.
• Maintained strict • To keep skin soft
hygiene, using and protect
mild soap, drying susceptible skin
gently and from breakdown.
thoroughly.
• Changed position • Improves
at least every two circulation.
hours.
• Massaged bony • Enhances
prominences circulation to
gently. tissues.
• Kept sheets and • Avoids friction.
bed clothes clean,
dry and free from
wrinkles, crumbs
and other irritating
agents.
• Provided safety • To prevent
measures. extensive damage
• Observed for • To prevent
decubitus ulcer extensive
development and damage.
assisted in
 administering
topical
applications.
(Mupirocin)

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENIONS RATIONALE EVALUATION

Objectives: Impaired oral m At the end of the • Assessed dental • Identifies -With white patches
-with Endotracheal ucous membranbe nursing health and oral prophylactic noted
tube related to intervention, the function treatment needs -Seen SO moistened
-With white patches endotracheal tube patient will • Brushed with soft • Prevents trauma the lips using
on oral cavity. insertion maintain the toothbrush or to delicate and slightly wet cotton
-with dry lips integrity of oral foam swab fragile tissues. balls
-with history of mucosa. • Kept lips moist • Promotes comfort
taking and prevent from
chemotherapeutic drying.
agents few days • Monitored for • Early recognition
prior to admission signs of oral super provides
GCS-3 infection opportunity for
prompt treatment.
• Suctioned as • To clear airway
needed after and prevent
giving oral aspiration.
hygiene.

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENIONS RATIONALE EVALUATION

Objectives: Constipation related At the end of the • Ascertained usual • Data required as -(+) bowel
- No bowel to decreased nursing elimination habits baseline for future movement.
movement for 4 peristalsis interventions, the evaluation of
days patient will therapeutic needs.
- GCS- 6 maintain usual • Assessed bowel • Defines problem.
- Weak in bowel consistency. sounds Constipation
appearance maybe a sign of
neurotoxicity.
• Monitored intake • Inadequate fluid
and output intake may
potentiate
complication
• Monitored • Electrolyte
laboratory studies imbalances may
as indicated such be a result or
as electrolytes contribute to
altered GI
function
• Administered IV • Prevents
fluids dehydration
• Administered • To prevent further
stool softeners complications