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NURSING CARE PLAN

Name of Patient: Mr. X Age/Sex: 55/MAttending Physician: Dr. AsoyCc: Lacerated wound

CUES NURSINGDIAGNOSIS

SCIENTIFICRATIONALE

OBJECTIVES IMPLEMENTATION RATIONALE EVA

Subjective: Nakilala ka haakon? asked bythe wife to thepatient.

Objective:Inability of the

patient torecognize his wifeand other personsthat surroundshim.

Impaired memoryrelated to traumaticevent evidence byinability torecognize patientswife

Head injury andinjury to the brainspecifically at thecerebral cortexwhich is responsiblefor memory storageis associated withtrauma, with greatmajority resultingfrom automobilecrashes. Whenforces exceedsabsorption capacityis transmitted to thebrain and tissuedamage result. Thistraumatic headinjury usuallycorrelates with theamount of force

After 3 days ofnursingintervention, thepatient will be ableto:1. Improve usualreality orientationby:

- reorientation ofhis ADLs with thehelp of S.O

2. Establishmethods inrememberingthings whenpossible with theS.O by:

- providing thingsthat were

Independent:

Allowadequate timefor client torespond toquestions/com

ments and tomakedecisions.

Discusshappenings ofthe past.

- Reaction time may beslowed with aging or braininjuries.

- To become more readilyrecalled by the client,because long term memoryusually remains intact.Reminiscence/ life review arebeneficial to the client.

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applied to thecranial contents.Typically the patientexperience a briefimmediate loss ofconsciousness

associated with leftparietal headfracture revealmotor- sensorydysfunction.

Source:Pathophysiology by:Barbara Bullock andReet HenzePage 946-947

significant to thepatient.

Reorient toperson/placeand time asappropriate.

Have clientrepeatverbal/writteninstructions

Involve inregularexercise,activity anddiversionalprograms.

Schedule atleast one restper day.

Maintainquiet, calmenvironment.

Encourageventilation offeelings offrustration,

- help client maintain focus.

- Verifies hearing/ ability toread and comprehend.

- Promotes release ofendorphins, enhancing senseof well-being, and improvethinking abilities.

-Prevents fatigue; enhancesgeneral well-being.

- To lessen anxiety.

- To lessen feelings ofpowerlessness/hopelessness.

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