nursing care plan

Description

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2.Explain pathophysiology of ICH
(active problem)

2. List specific reason why each medication is prescribed, side effects, contraindications and nursing implications/teaching

Lab and Diagnostic Tests Discuss how these tests and results pertain specifically to the patient’s condition.

3. Contains 5 priority nursing diagnosis NANDA approved including psychosocial. Interventions included in order. (List all nursing diagnoses that apply to your patient scenario in priority order and indicate whether each diagnosis was client, nurse, or mutually derived).

4. Evidence based rationale for each intervention and for each priority nursing diagnosis. Cite references in APA format.

Active problems:

Nontraumatic cortical hemorrhage of right cerebral hemisphere

Spasticity

Gait abnormally

Left hemiparesis

Urinary tract infection

Primary hypertension

Medications:

baclofen 5 mg oral

bisacodyl 10 mg rectal

amlodipine 10 mg oral

heparin 5,000 units subcutaneous

lidocaine 5% 1 patch transdermal

meropenem 500 mg iv infusion

nystatin topical

Labs:

Sodium: 147

Potassium: 4.5

Chloride: 110

CO2: 27.4

BUN:19

Creatinine: 0.4

Glucose: 116

ALT: 214

AST: 67

ALK PHOS: 162

Bilirubin: 0.6

Calcium: 9.2

Total protein: 6.6

Albumin: 3.6

Magnesium: 2.5

Phosphorus: 3.0


Unformatted Attachment Preview

Subjective Data that
supports the nursing
diagnosis:
Client Outcomes
Nursing Interventions
Rationale
Objective Data that
supports the nursing
diagnosis:
NURSING DIAGNOSIS:
(for example )Ineffective Breathing Pattern related to hypoxia as evidence by shortness of breath
Evaluation
Nursing diagnosis:
Subjective Data that
supports the nursing
diagnosis:
Objective Data that
supports the nursing
diagnosis:
Client Outcomes
Nursing Interventions
Rationale
Evaluation
Nursing diagnosis:
Subjective Data that
supports the nursing
diagnosis:
Objective Data that
supports the nursing
diagnosis:
Client Outcomes
Nursing Interventions
Rationale
Evaluation
Nursing diagnosis:
Subjective Data that
supports the nursing
diagnosis:
Objective Data that
supports the nursing
diagnosis:
Client Outcomes
Nursing Interventions
Rationale
Evaluation
Nursing diagnosis:
Subjective Data that
supports the nursing
diagnosis:
Objective Data that
supports the nursing
diagnosis:
Client Outcomes
Nursing Interventions
Rationale
Evaluation
Nursing diagnosis:
Subjective Data that
supports the nursing
diagnosis:
Objective Data that
supports the nursing
diagnosis:
Client Outcomes
Nursing Interventions
Rationale
Evaluation
Discharge Plan:
Previous community resources:
Community resources needed for this discharge:
Discharge teaching plan:
Theoretical Framework which guided the nursing interventions (included discussion of the dimension of interaction and other
theoretical concepts that you have used)
Research Topic:
Reflection:

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