Other signs that may be present are increased vital signs from baseline vitals, crying, moaning, facial mask of pain, or a guarded position. Pupils are unequal with sluggish response to light neurologicĪssessment scale score is _ patient is still experiencing memory loss and unable to state correct month.įrequent neuro checks will continue.The defining characteristic for a nursing care plan for acute pain is that the patient must report or demonstrate signs of discomfort. Some signs of discomfort include nausea, itching, vomiting, or pain. No neurologic deficits are evident at this time. Neurologic scale score is within normal limits. Patient is alert and oriented X3 with clear speech and cognitiveįunction. Patient demonstrates optimal cerebral perfusion AEB pupils are now round equal andīriskly reactive to light and accommodate. If goal is still not met, briefly state an State if goal was met, partially met or unmet and provide supporting data. State paient response: _ĪCTUAL OUTCOME: Goal Met Partially Met Not Met Pupils are equal, round, briskly reacive to light and accommodate.Ģ. Performing frequent neurologic checks using a standardized scale will assist in detecing early neurologic deterioraion (Connors, 2009)Ģ. Administer as prescribed: Ringer’s Lactate IV at 50 mL/hr for 24 hours.ġ. Perform neurological assessments using Glasgow scale Q 1 hour X 24 hrs.Ģ. Tg 5/ NURSING INTERVENTIONS: NURSING INTERVENTION EVIDENCE BASED RATIONALE EVALUATION OF INTERVENTIONġ. No change in orientaion or consciousness or memory prior to discharge Pupils equally reacive to light and accommodate within 2-4 hours Paient will demonstrate opimal cerebral funcion throughout hospitalizaion as evidenced by: Within_ (state reasonable ime frame 12- 24 hours, 1-2 days, prior to discharge, etc.)
State a client centered goal with measurable outcome criteria and reasonable ime frame.Įxample: Paient will demonstrate, achieve, maintain, report, state, ambulate, self inject, etc. Impaired Cerebral Tissue Perfusion related to efects of recent head injury AEB report of loss of consciousness lasing 10 minutes, memory impairment and unequal pupils L>R. P+RF format: Potenial Problem/AEB/Risk Factors
Objecive: List the following indings only if Reports symptoms of (locaion, intensity,etc) The development of a relevant Nursing Diagnosis for each problem.