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is this correct? this is my ncp for CVA bleed patient (unconscious)

I-physiologic need

Objective cues: unconscious, capillary refill of 7 secs, skin temp changes

Objectives of Care:

After nursing interventions, the patient will be able to:

  • maintain patent airway
  • b. maintain cerebral perfusion by having a BP of 20 percent less than usual highest BP obtained

Nursing Interventions:

  • assess pt. vital signs especially BP to provide customary baseline data for comparison with current findings
  • assess its ability to clear secretions to decrease o2 demand/decrease risk of aspiration
  • elevate head of bed and maintain head/neck in midline and neutral position to promote circulation and venous drainage
  • assist hypothermic therapy to decrease metabolic and O2 need
  • o2 saturation monitoring to evaluate o2 levels
  • monitor skin integrity and a provide a turning schedule to prevent skin breakdown
  • encourage quiet restful environment to conserve energy /lowers o2 tissue demand
  • administer prescribed medication to treat underlying cause

APBT mom, LPN, RN

Specializes in Med/Surg, Tele, IM, OB/GYN, neuro, GI.

I-physiologic need

Objective cues: unconscious, capillary refill of 7 secs, skin temp changes

Objectives of Care:

After nursing interventions, the patient will be able to:

  • maintain patent airway
  • b. maintain cerebral perfusion by having a BP of 20 percent less than usual highest BP obtained

Nursing Interventions:

  • assess pt. vital signs especially BP to provide customary baseline data for comparison with current findings
  • assess its ability to clear secretions to decrease o2 demand/decrease risk of aspiration
  • elevate head of bed and maintain head/neck in midline and neutral position to promote circulation and venous drainage
  • assist hypothermic therapy to decrease metabolic and O2 need
  • o2 saturation monitoring to evaluate o2 levels
  • monitor skin integrity and a provide a turning schedule to prevent skin breakdown
  • encourage quiet restful environment to conserve energy /lowers o2 tissue demand
  • administer prescribed medication to treat underlying cause

What are you using as the NANDA?

The only thing I would change is what I bolded. The way I read that line it should say assess the patients ability.....

You know it's a patient so state that.

Other than that it looks fine to me.

What semester are you? From my experience (don't know if this is expected for anyone else), when writing care plans, always ask yourself how and include it and when (q2h, q4h, etc.) List the medication you are giving to help with that diagnosis and assess for s/e as well as therapeutic effects (give examples). Hope that helps.

Blee O'Myacin, BSN, RN

Specializes in ED, ICU, Heme/Onc.

You mentioned before that this is an ER patient, right? When I have an acute bleeder, I watch for the airway and keep an eye on the LOC and vital signs, and get them out to a facility that has neurosurgery ASAP.

Your rationales sound good. Stick to the ABC's, find your NANDA labels and apply all your information. Nice work, you are almost done!

Blee

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt.

"monitor skin integrity and a provide a turning schedule to prevent skin breakdown" has nothing to do with your objectives of care which are to maintain a patent airway and maintain cerebral perfusion. It, in fact, does not belong with this diagnosis. It has to do with skin integrity. You need to remove it.

"administer prescribed medication to treat underlying cause"--What do you mean by underlying cause? I think you can be specific about what you are going to give medication to this patient for: elevated BP or to control hemorrhage.

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