Cues

Subjective Cues:
She was admitted last April 1, 2015due
to a decrease in sensorium. Though she
was conscious during that time, she
experienced vomiting, difficulty of
breathing, bowel and urinary
incontinence. Her BP already reached
240/100. She was managed under
antihypertensive medications.

The family noticed that she became

difficult to arouse. She became febrile
and her BP increased. Her swallowing
became impaired wherein she cannot
anymore take in food. It prompted the
family to take her to PGH last April 23,
2015

Objective cues:
VITAL SIGNS
RR- 20 breaths/minute (regular)
Heart rate: 74 bpm (regular)
T- 36.9C (Axilla), PR- 73bpm (regular,
strong pulse)
BP- 190/80 (lying), (-) Signs of distress
ANTERIOR CHEST Good skin turgor,
regular breathing pattern, Equal and clear
breath sounds
(+) rhonchi @ both middle to lower lung
fields, (-) crackles, wheezes, rhonchi, pleural
friction rub, Precordial area flat, adynamic,
(-) lifts, thrill, tenderness
HR: 74 bpm, regular, distinct heart sounds,
S1>S2@apex, S1<S2@base,
(-) murmurs
UPPER BACK AND SIDE
Inspiration-Expiration ratio: 1:2, (-) use of
accessory muscles, Chest symmetric, APL
ratio: 1:2 Symmetric chest expansion,
Lateral: clear and equal breath sounds
Contraptions:

Nursing Diagnosis
Impaired
spontaneous
ventilation related to
brain injury
secondary to Acute
CVD

Background Knowledge
According to NANDA,
impaired spontaneous
ventilation is a decrease in
energy reserves that
results in an individuals
inability to maintain
breathing adequate to
support life.
An airway problem is
always the priority problem
that the nurse should
address immediately.
Cerebrovascular disease is
a sudden impairment of
cerebral circulation in one
or more of the blood
vessels supplying the
brain. This pathology either
causes hemorrhage from a
tear in the vessel wall or
impairs the cerebral
circulation by a partial or
complete occlusion of the
vessel lumen with transient
or permanent effects.
Respiratory impairment is
one of the life-threatening
effects that it have caused.

Goals and objectives

Goal:
After the nursing
interventions, the client
will demonstrate or
maintain effective
respiratory pattern via
mechanical ventilator.
Objectives:
After the nursing
interventions, the
patient will:

NOC: Mechanical
ventilation response,
adult (496)

Maintain vital
signs within
normal limits
Maintain
respiratory rate
within normal
limits

Maintain regular
respiratory
rhythm and depth

Maintain clear
bilateral breath
sounds

Manifest absence
or a decrease in
intensity of
rhonchi
bilaterally @ all
lung fields

Nursing interventions

Standard Criteria

The nurse will:

The client:

NIC: Respiratory functioning (3350)

NOC: Mechanical ventilation

response, adult (496)

Monitor vital signs especially q1h

Monitor overall breathing pattern,

distinguishing between spontaneous
respirations and ventilator breaths.

Indicators:

Rationale: Client is completely dependent on

the mechanical ventilator

Auscultate for presence of breath

sounds bilaterally

Rationale: To ensure that air is effectively

provided

Verify that clients respirations are in

phase with the ventilator

Note chest movement, watching for

symmetry, use of accessory muscles
and supraclavicular and intercostal
muscle retractions

NIC: Artificial Airway Management [3180]

Provide an oropharyngeal airway block or
bite block

Respiratory rate:
Respiratory rhythm:
Depth of inspiration:
Tidal Volume:
FiO2:
O2 saturation:
Breath sounds:
Adventitious breath sounds:
Asymmetrical chest wall
movement:
Asymmetrical chest wall
expansion: +/Respiratory secretions:

ET size: 7.5, level 22 attached to Mechanical

ventilator, on AC Mode
Settings: FIO2: 60%, TV: 400 PF: 60, PEEP:
5 cm
c NGT @ L nose, patent, in place

Rationale: Prevent biting on the endotracheal

tube, as appropriate

Medications:
Salbutamol + ipratropium
Laboratory Findings:

Check cuff inflation periodically and

whenever cuff is deflated/reinflated

pH
pCO2
pO2
HCO3
-

7.458
Alkalotic
25.1
Decreased
109.9
Increased
17.8
Decreased
Indicates fully compensated
respiratory alkalosis

Cranial CT Scan Impression:

April 12, 2015
Acute Infarct R frontal lobe
Lacuna infarct, Rbasal ganglia
Periventricular + subcortical white matter
ischemic changes probably 2 to small vessel
arteriosclerosis
Central cortical cerebral atrophy
Ethmoid and R maxillary sinusitis

Provide 100% humidification of inspired

gas/air

Rationale: To prevent risks associated with

under/overinflation
Check tubings for obstruction
(e.g. kinkings and H2Oprecipitates)
Rationale: They might impede flow of oxygen
Monitor ventilator settings routinely:
Check tidal volume set to volume needed for
individual situation and proper functioning
of bellows
Rationale: To reduce risk to complications
associated with alteration n lung compliance
Monitor airway pressure
Rationale: To immediately note possible
respiratory complications
Perform endotracheal suctioning with sterile
technique, as appropriate
Evaluate amount and type of secretions being
produced.
Rationale: Excessive and/or sticky mucus can
make it difficult to maintain effective airways.
Provide mouth care and suction oropharynx,
as appropriate
NIC: Airway Management (3140)
Elevate head of the bed to 30 degrees/change
position, as needed.

Rationale: Elevation/upright position facilitates

respiratory function by use of gravity
Encourage/provide warm versus cold liquids,
as appropriate.
Rationale: Warm hydration can help liquefy
viscous secretions and improve secretion
clearance.
Provide nebulization with salbutamol +
ipratropium or PNSS (if med is unavailable)
as needed.
Rationale: To reduce viscosity of secretions
Perform chest physiotherapy, as ordered

Cues
Subjective Cues:

Patient has chronic hypertension for 31

years. She managed it with neoblock.
She was admitted last April 1, 2015due
to a decrease in sensorium. Though she
was conscious during that time, she
experienced vomiting, difficulty of
breathing, bowel and urinary
incontinence. Her BP already reached
240/100. She was managed under
antihypertensive medications.
The patient, due to the paralysis of her
both legs, was bounded to a wheel
chair and fully depended on self-care
activities such as feeding, toileting,
bathing, and grooming. No memory
impairments were noticed. Significant
other verbalized that the patient was
still oriented to people, time, and place.
She had difficulty in speaking wherein
she only produced indistinguishable
sounds which was described as ilingiling lang.

Nursing Diagnosis
Ineffective cerebral
tissue perfusion
related to frequent
episodes of increased
BP secondary to
Acute CVD

Background Knowledge
According to Doenges,
ineffective cerebral tissue
perfusion is a state in which
a decrease in cerebral
oxygen supply results in the
failure of the nourishment
of tissues in the capillary
level.
Cerebrovascular disease is
a sudden impairment of
cerebral circulation in one
or more of the blood
vessels supplying the
brain. This pathology either
causes hemorrhage from a
tear in the vessel wall or
impairs the cerebral
circulation by a partial or
complete occlusion of the
vessel lumen with transient
or permanent effects.

Goals and Objectives

Goal:
The client will
demonstrate improved
cerebral perfusion.

Objective:
After the nursing
interventions, the client
will:
NOC: Tissue
Perfusion: Cerebral
[0406]
Maintain systolic
blood pressure <- 160.
Maintain diastolic
blood pressure <-80

Maintain mean arterial

pressure 130-160
mm/Hg

Nursing Interventions

Standard Criteria

The nurse will:

The client:

NIC: Cerebral Perfusion Promotion [209]

NOC: Tissue Perfusion: Cerebral

[0406]

Monitor Neuro vital signs q1h

Monitor Vital Sign q1h especially

Blood pressure

Rationale: Blood pressure can be indicative of

cerebral perfusion impairment.
Hypertension can precipitate
cerebrovascular spasm
Hypotension causes inadequate
perfusion of brain -> changes in
consciousness

Systolic blood pressure <- 160:

________
Diastolic blood pressure <80:_______
Mean arterial pressure 130-160
mm/Hg:__________

NOC: Neurologic Status:

Consciousness [0912]

The family noticed that she had a

persistent increase in sleeping time and
she became difficult to arouse. She
became febrile and her BP increased.
Her swallowing became impaired
wherein she cannot anymore take in
food. It prompted the family to take her
to PGH last April 23, 2015
There is a family history of
hypertension and stroke.

NOC: Neurologic
Status: Consciousness
[0912]
Improve Glasgow
Coma Scale
NOC: Neurological
status [0909]
Improve
Pupillary reaction

Objective cues:
VITAL SIGNS
RR- 20 breaths/minute (regular)
Heart rate: 74 bpm (regular)
T- 36.9C (Axilla), PR- 73bpm (regular,
strong pulse)
BP- 190/80 (lying), (-) Signs of distress
GENERAL SURVEY
Stuporous, mesomorph, well-developed,
looks according to age
Mental Status: Unconscious, E(1)VTM(3)=4
Pupillary reflex: Equal, 3/3 mm pupils,
Nonreactive R/L,
(-)
corneal reflex, dolls eyes
ANTERIOR CHEST Good skin turgor,
regular breathing pattern, Equal and clear
breath sounds
(+) rhonchi @ both middle to lower lung
fields, (-) crackles, wheezes, rhonchi, pleural
friction rub, Precordial area flat, adynamic,
(-) lifts, thrill, tenderness
HR: 74 bpm, regular, distinct heart sounds,
S1>S2@apex, S1<S2@base,
(-) murmurs
UPPER BACK AND SIDE
Inspiration-Expiration ratio: 1:2, (-) use of
accessory muscles, Chest symmetric, APL
ratio: 1:2 Symmetric chest expansion,
Lateral: clear and equal breath sounds

Maintain regular
breathing pattern
Maintain 60-80 mmHg
pulse pressure

Rationale: Mean arterial blood pressure should

be maintained above 90 mm Hg to maintain
cerebral perfusion pressure (CCP) > 70 mm
Hg, which reflects adequate blood supply to the
brain

Maintain radial pulse

rate to 60-100 bpm

Monitor fluid and electrolytes

status.

Rationale: Imbalances can have a direct

bearing on brain perfusion and function.

Monitor fluid intake and output

Monitor for signs of fluid overload

such as rhonchi, crackles, JVD,
edema and increase in pulmonary
secretions

Elevate HOB to 30 degrees

Hyperthermia
Maintain apical heart
rate to 60-100 bpm

Monitor mean arterial pressure

Rationale: Optimal head of bed position is

determined by both ICP and CPP
measurementsthat is, which degree of
elevation lowers ICP while maintaining
adequate cerebral blood flow.4 Studies show
that in most cases, 30 degrees elevation
significantly decreases ICP while maintaining
cerebral blood flow. (Doenges)
Rationale: to promote circulation/venous
drainage.

Maintain head/neck in neutral

position, supporting with small
towel rolls or pillows to maximize
venous return.

Rationale: Lateral and rotational neck flexion

has been shown to be the most consistent
trigger of sustained increases in ICP

Avoid causing hip flexion of 90

degrees or more.

GCS:
E:
V:
M:
NOC: Neurological status [0909]
Indicators:
Pupil size: ________
Pupil reactivity: ______
Eye movement
pattern:_______________
Breathing
pattern:_______________
Pulse pressure:______
Respiratory rate:_____
Hyperthermia:_______
Apical heart rate:_____
Radial pulse rate:_____
Cognitive status:________

REFLEXES
Babinski: (+)
ASSESSMENT OF 12 CRANIAL NERVES:
CN I: cannot be assessed
CN II: cannot be assessed
CN III, IV, VI: Pupils: Equal, 3/3 mm, NR
L/R, (-) dolls eye
CN V: (-) corneal reflex, facial sensation:
cannot be assessed
CN VII: cannot be assessed
CN VIII: cannot be assessed
CN IX & X: (+) gag reflex
CN XI: cannot be assessed
CN XII: cannot be assessed
Contraptions:
C ET size: 7.5, level 22 connecting to
Mechanical ventilator, on AC Mode
Settings: FIO2: 60%, TV: 400 PF: 60, PEEP:
5 cm
C IVF @ L Saphenous vein, intact, (-)
redness, swelling connecting to PNSS 1 L x
14 hours
Medications:
Nimodipine 30 mg 1 tab 2 tabs q4h
Carvedilol 25 mg 1 tabBID
Lactulose 30 cc BID NGT
Levetiracetam 500 mg t ab bid
Telmesartan +
Hydrocitcorotitiazide (HCTZ)
80/25 g OD
Laboratory Findings:
CBC
WBC
RBC
Hgb
Hct
pH
pCO2
pO2
HCO3

Result
9.13
3.45
97
0.31
7.458
25.1
109.9
17.8

Remarks
Normal
Decreased
Decreased
Decreased
Alkalotic
Decreased
Increased
Decreased

Rationale: Hip flexion may trap venous blood

in the intra-abdominal space, increasing
abdominal and intrathoracic pressure, and
reducing venous outflow from the head,
increasing cerebral pressure.

Administer Mannitol 150cc fast

drip, as ordered

Rationale: Mannitol is an osmotic diuretic

which is administered to prevent cerebral
edema and increased ICP

Administer Nicardipine 100 cc @

10cc/hr, as ordered

Rationale: Nicardipine is a Calcium Channel

blocker which is administered to decrease the
patients BP to <- 160/80
NIC: Cerebral Edema Management [207]
Suction with caution and only when needed,
limiting to two passes of 10 seconds each with
negative pressure no more than 120 mm Hg.
Rationale: Prolonged suctioning can increase
intracranial press
Hyperoxygenate before suctioning, as
appropriate
Rationale: To prevent hypoxia
Routine hyperventilation is to be avoided;
however, therapeutic hyperventilation (PaCO2
of 30 to 35 mm) may be used for a short period
of time in acute neurological deterioration to
reduce intracranial hypertension, while other
methods of ICP control are initiated
Administer Lactulose 30 cc, as appropriate
Rationale: To avoid Vasalva maneuver. Vasalva
maneuver v=can trigger increased ICP
Turn patient q2h and Perform passive ROM
exercises

Cranial CT Scan Impression: April 12, 2015

Rationale: Promote good circulation and avoid

bed sores

Acute Infarct R frontal lobe

Lacuna infarct, R basal ganglia
Periventricular + subcortical white matter
ischemic changes probably 2 to small vessel
arteriosclerosis
Central cortical cerebral atrophy
Ethmoid and R maxillary sinusitis

Minimize extraneous stimuli (e.g., quiet

environment, soft voice, back massage, gentle
touch as tolerated)
Rationale: To reduce CNS stimulation which
can trigger increased ICP
Encourage family to talk to client
Rationale: familiar voices appear to have a
relaxing effect on many comatose individuals
(thereby reducing ICP)
Administer enteral milk feeding (312 cc), as
ordered
Rationale: To achieve positive nitrogen
balance, reducing effects of post-brain injury
metabolic and catabolic states, which can lead
to complications
NIC: Seizure Precaution [630]

Cues
Subjective Cues:

Nursing Diagnosis
RC: Sepsis

Background knowledge
According to Carpenito-

Goal and Objectives

Goal:

Monitor compliance in taking

anticonvulsant Levetiracetam 500
mg t ab bid

Instruct family on potential

precipitating factors

Instruct family about seizure first

aid

Remove potentially harmful

objects from the environment

Keep suction at bedside

Keep ambu bag at bedside

Nursing Interventions

Standard Criteria

According to significant other,

patient gets sick easily

Patient was admitted to PGH last April

23, 2015

Patient was admitted with no

pulmonary infection until April
26, 2015 as evidenced by GS/CS
result.

Objective cues:
Aerobic Culture and Sensitivity: Blood April
26, 2015
Staphylococcus epidermis: (+) after 2 days of
incubation
April 27, 2015 Gram Staining: Blood
Gram (-) Bacilli: 0-2 OIF
Contraptions:
C ET size: 7.5, level 20 attached to
Mechanical ventilator, on AC Mode
Settings: FIO2: 60%, TV: 400 PF: 60, PEEP:
5 cm
C IVF @ L Saphenous vein, intact, (-)
redness, swelling connecting to PNSS 1 L x
14 hours
C heplock @ R metacarpal vein, intact, (-)
redness, swelling
C NGT @ L nose, patent
C foley catheter

VITAL SIGNS
RR- 20 breaths/minute (regular)
Heart rate: 74 bpm (regular)
T- 36.9C (Axilla), PR- 73bpm (regular,
strong pulse)
BP- 190/80 (lying), (-) Signs of distress

Moyet, possible
complication: sepsis is
described when a person is
experiencing or at high risk
to experience a systemic
response to the presence of
pathogenic bacteria,
viruses, fungi, or their
toxins. The microorganisms
may or may not be present
in the bloodstream.
Sepsis is SIRS plus the
presence of an infection.
Systemic inflammatory
response syndrome is
described as a
systemic level of acute
inflammations as
manifested by elevated
WBC count,
hypo/hyperthermia,
tachypnea and tachycardia.

The patient will not

manifest any signs and
symptoms of sepsis.

Objective:
After the nursing
interventions, the
patient will:

The nurse will:

The patient:

NIC: Infection Control (6540)

NOC: Infection Severity [0703]

Monitor vital signs esp BP to maintain

MAP >65

Monitor for signs and symptoms of sepsis:

NOC: Infection
Severity [0703]
Manifest BP <-160/80
Manifest temp not >38
C or <36 C
Manifest heart rate
>100 bpm

Sepsis causes vasodilation and capillary leak

resulting in hypovolemia.
Rationale: Monitoring reduces mortality
[Picard et al., 2006]

Signs of infection around site:

Manifest respiratory
rate >20 breaths/min
Manifest absence of
rash, purulent sputum,
fever, and
lymphadenopathy

Instruct visitors for s/sx of sepsis

Rationale: Significant others will know when to

call the doctor/nurse

Assess for evidence of adequate tissue

perfusion: heart rate, respirations, urine
output

Practice VAP Bundles of care

1. Elevation of the head of the bed (HOB)

2. Daily sedation vacations and assessment of
readiness to extubate
3. Peptic ulcer disease prophylaxis
4. Deep vein thrombosis (DVT) prophylaxis
5. Daily oral care with chlorhexidine

GENERAL SURVEY
Stuporous, mesomorph, well-developed,
looks according to age
Mental Status: Unconscious, E(1)VTM(3)=4

Rash -/+
Purulent Sputum -/+
Fever: -/+
Lymphadenopathy: +/Site:
Temperature 36.5-37.4
Pulse 60100 beats/min
RR 12-20 breaths/min
BP: 90-130/60-90

Encourage to maintain adequate hydration

and electrolyte balance

Rationale: To prevent imbalances that would

predispose to infection.

+/-Redness
+/- Erythema
+/-Swelling
+/-Pain
+/-Fever

Pupillary reflex: Equal, 3/3 mm pupils,

Nonreactive R/L,
(-)
corneal reflex, dolls eyes

ANTERIOR CHEST Good skin turgor,

regular breathing pattern, Equal and clear
breath sounds
(+) rhonchi @ both middle to lower lung
fields, (-) crackles, wheezes, rhonchi, pleural
friction rub, Precordial area flat, adynamic,
(-) lifts, thrill, tenderness
HR: 74 bpm, regular, distinct heart sounds,
S1>S2@apex, S1<S2@base,
(-) murmurs

UPPER BACK AND SIDE

Inspiration-Expiration ratio: 1:2, (-) use of
accessory muscles, Chest symmetric, APL
ratio: 1:2 Symmetric chest expansion,
Lateral: clear and equal breath sounds
(+) bed sore @ sacrum

Medications:
PipeTazo 4.5 g q8h IV
Laboratory Findings:
CBC
WBC
RBC
Hgb
Hct

Result
9.13
3.45
97
0.31

Remarks
Normal
Decreased
Decreased
Decreased

Cranial CT Scan Impression: April 12, 2015

Acute Infarct R frontal lobe
Lacuna infarct, Rbasal ganglia
Periventricular + subcortical white matter
ischemic changes probably 2 to small vessel
arteriosclerosis
Central cortical cerebral atrophy
Ethmoid and R maxillary sinusitis

Administer/monitor medication
regimen
Piperacillin Tazobactam 4.5 g IV q8h
Practice proper hand washing and aseptic
techniques.

Rationale: A first line defense against

healthcare-associated infections (HAI)

Maintain clean, well-ventilated

environment

Maintain sterile technique for invasive

procedures such as endotracheal care

Cleanse incisions/insertion sites daily and

as needed with povidone-iodine or other
appropriate solution to prevent growth of
bacteria.

Perform wound cleaning at bed sore with

Flammazine ointment