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Nursing Care Plan

For Patient With SAH

Aging Ward

Khon Kaen Hospital

Created By :

Maryudela Afrida

Nursing Departement

Universitas Muhammadiyah Yogyakarta

2013
Nursing Assesment

1. Identity
Name : Mr. W
Ward : Adult Ward
Age : 37 yr.
Sex : Male
Medical Diagnose : Status Epileptikus
Assesment Date : 13 November 2013
2. Chief Complain
The patient unconscious, get intubation with bird ventilator. Patient cannot eat
because the ventilation.
3. Health History
a. Past History
The patient was alcohol drinkers since 10 years ago. He has smoking history.
b. Recent History
The patient has been shocked 2 hours before enter the hospital. He has been
brought to the Ubonlart Hospital, but he referred to the Khon Kaen Hospital.
When he canme to the Khon Kaen Hospital, he was unconciuss, and difficult to
breath.
4. Physical Examination
a. Head
No Hematom, ananemis conjunctiva, unicteric sclera, the hair is wet caused by
evaporation, there was no secret in the nose, mucous membran was pink. There is
an oropharingeal and endotracheal tube in his mouth, it was dirty. There is a little
secret in the mouth.
b. Neck
Nothing enlargement of the tyroid gland and lymph.
c. Lung
Inspection : there was sternum depression, and aditional respiration
muscle.
Percution : dullness
Auscultation : crepitation, wheezing, and ronchi.
d. Heart
Inspection : ictus cordis is not seen.
Percution : dullness
Auscultation : s1-s2 regular.
e. Abdomen
Inspection : Abdomen is flat, nothing tenderness.
Auscultation : 8 x/mnt.
Percution : tymphani.
f. Ekstermity
Upper : motoric scale is 6, sometime it was agitation, no pitting
edema.
Lower : motoric scale is 6, sometime it was agitation, no pitting
edema.
5. Laboratory Test

Kind Date Unit Normal Range Result


10/11/2013 11/11/2013 12/11/2013
CBC
RBC 3,72 4,41 10^6/uL 4,50-6,30 Low
Hemoglobin 10,5 12,6 g/dL 13-17,4 Low
Hematokrit 31,2 37,2 % 40,0-54,0 Low
MCHC 33,7 33,9 g/dL 31,3-33,4 Low
PLT 97 72 10^3/uL 140-440 Low

WBC GROUP
Netrofil 94,4 88 % 43,7-70,9 High
Limfosit 2,5 6,6 % 20,1-44,5 Low
Eosinofil 0 0 % 0,7-9,2 Low

Blood Chemistry
BUN 30 mg/dL 6 - 20 High
Cr 2,42 mg/dL 0,70-1,20 High
Albumin 3,4 g/dL 3,5-5,2 Low
Co2 19,5 mMol/L 22,0-29,0 Low
Calsium 6,7 mg/dL 8,6 - 10,2 Low
Fosfor 2,5 mg/dL 2,7-4,5 Low

Liver function Test


Bilirubin Direct 0,6 mg/dL 0,0-0,2 High
ALT (SGPT) 2281 U/L 0-41 High
ALT (SGOT) 6721 U/L 0-40 High
Cholestrol 219 mg/dL <200 High

Blood Gas
pCO2 29,7 mmHg 35-45 low
PO2 401,3 mmHg 83-108 high
TCO2 20,5 mMol/L 21-32 low
Hct 34 % 40-54 low
PATOFISIOLOGY OF STATUS EPILEPTICUS

Potential to sepsis
due to pneumonia

Pneumonia Heavy drinking


6.

Aspiration Disturb brain Inappropriate eating

Seizure Nutritional status changed

Potential to O2
O2 inhale
Conscious changed impairment due to
decrease
ineffective respiration
from seizure

Immobility

Potential to O2
O2 ET & Ventilator (Bird) impairment due to
impairment ineffective respiration
from seizure

Potential to O2 Can’t eat due to ET


impairment due to
ineffective respiration
from seizure
Nursing Diagnosis, Outcome and Intervention

No Nursing Diagnosis NOC Nursing Activities Evaluation


Statement (Objective &
Criteria)
1. Potential to sepsis Client Outcomes 1. Assess possible  After tepid sponge
The sepsis not
due to Pneumonia etiology of and paracetamol
being held with
Data : the criteria : increased syrup the fever of the
 T : 410 C. temperature. patient is decrease
 Infection
 The extermity not spread 2. Assess (38,5o C).
to all the
temperature is body.
temperature  Patient look relax
hot  Temperature every 2 hours. and comfortable.
(36,5-37,40
3. Encourage fluids
C).
 The skin when indicated.
temperature
4. Collaboration for
is not warm
to touch. administer anti
 The skin
microbial, and
color not
pale and antiviral as
redness.
appropriate.
5. Administer tepid
sponge bath
and/or apply
cool cloths to
groin and
axillae.

2 Potential to O2 Client Outcomes 1. Assess for signs  After change


Patient's
impairment due to and symptoms of positioning semi
breathing
ineffective an ineffective fowler patient still
pattern is
respiration from breathing pattern using additional
maintained as
seizure. (e.g. shallow or respiratory muscle
evidenced by:
Data : slow  RR: 30 x/minute.
 Eupnea
 There was a respirations).  After suction and
 Oxygen 2. Positioning client
depression mouth care, the
sternum. Saturation > in a semi - to sound of auscultation
 RR : 30 x/mnt. 95 %. high Fowler's. (wheezing and
 Dispnea.  Regular 3. Consult ronchi) is decrease.
respiratory appropriate  Patient still have
rate/pattern. health care secretion in her
 There is provider (e.g. mouth but still have
sputum in physician, a little secretion on
the airway. respiratory her mouth and ET
 The lung therapist) if: tube.
sound is signs and
ronchi in symptoms of
some part. impaired gas

 Maintains a exchange (e.g.

patent restlessness,

airway at all irritability,

times confusion,

 Identifies significant

and avoids decrease in

specific oximetry results,

factors that decreased PaO2

inhibit and increased

effective PaCO2 levels) are

airway present.

clearance. 4. Auscultate

 No Breath Sound.

Cyanosis. 5. Monitor
respiratory
 Good
patterns,
Conscious.
including rate,
depth, and effort.
6. Monitor blood
gas values and
pulse oxygen
saturation levels
as available.
7. Assist with
clearing
secretions from
pharynx by
suction of the
oral pharynx if
necessary.
8. Provide oral care
every 4 hours.
9. Administer
oxygen as
ordered.
3. Cannot eat due to Client Outcomes 1. Determine  Risk for imbalanced
Patient receiving
ET. healthy body nutrition problem
food
Data : appropriately weight for age resolved with NGT
and prevention
 Patient used ET of nutritional and height. feeding.
and ventilator. status changed 2. Assess client's  Patient get feeding
evidenced by :
 The patient ability to obtain from NGT 300 ml
cannot eat  Patient and use essential and 100 ml water.
received
byself. feedding as
nutrients.  Patient given
docter 3. Give the intravenous therapy :
perscreption
aditional D5%
(300ml x ...)
 Weight, nutrition by
BMI, MAC
orogastric tube.
(Mid Arm
Circle), TSF 4. Evaluate client's
is within
laboratory
normal
range. studies (serum
 Free of signs
albumin, serum
of
malnutrition total protein,
serum ferritin,
transferrin,
hemoglobin,
hematocrit,
vitamins, and
minerals).
5. Consult with
dietitian for
actual calorie
count.
4. Potential to Client Outcomes 1. Reposition the pt  Risk for Impaired
The skin
pressure ulcer due at least once skin integrity
integrity is good
to immobility evidenced by : every two hours. problem solved
Data : 2. Keep the skin partially with
 No Wound
 patient got clean and dry. reposition patient
 Regains
bedrest at long 3. Monitor skin regularly
integrity of
time. condition at least
skin surface
once a day for
 Pt’s skin has
color or texture
no signs of
changes,
worsening or
dermatological
advanced
conditions, or
impairment.
lesions.
5. Can’t do ADL Patient 1. Assess patient's  In this case, patient
(bathing/hygiene, Outcomes need for cannot capable to
toileting, and The patient’s assistive compliance ADL
dressing) related to self care being devices. with own self but
immobilization. done by assisted 2. Assist patient in this problem has
Data : the nurse accepting been solved with
 Patient got evidenced by : necessary assistance from nurse
bedrest at long  The mouth is amount of and family to
time. clean, dependence. implement ADL
 Patient can’t mucose 3. Provide privacy
take a bath, membran is during dressing.
toileting, and moist. 4. Provide
dressing by him  The skin is frequent
self. clean, and assistance as
the integrity needed with
is good. dressing.
5. Maintain
privacy during
bathing as
appropriate.
6. Assist patient in
removing or
replacing
necessary
clothing and
assist patient to
getting bath.
7. Give the patient
pampers to
assist the
toileting.
8. Do the mouth
care periodicly.

SUMMARIZE

The family ask permission to the docter, to bring the patient go home. The family kept
the Thai culture that every people in their family should die in the home. The family bring the
patient go back to the home at 13 November 2013 night.