KATHMANDU UNIVERSITY

SCHOOL OF MEDICAL SCIENCES

DHULIKHEL, KAVRE

Medicine care plan

Submitted to: Submitted by:

Ms. Subina Manandhar Rekha Adhikari

Assistant Professor Roll No: 2
KUSMS BNS 2nd year
DEMOGRAPHIC DATA
Name Ms Thulikanchi Ghorasainee
Age 84 years
Sex Female
Hospital no
Bed no 7 ‘B’
Address
Ward Medicine ward
Admission date 2023/12/02
Diagnosis 1. Ischemic Stroke involving left MCA with right-sided hemiplegia

Chief Complains:
Right-sided weakness for 1 day
Vomiting 4 episode
Actual Nursing Diagnosis

1. Impaired physical mobility related to neuro-muscular dysfunction and decreased

muscle strength and control related to neuronal dysfunction caused by decreased
cerebral perfusion.
2. Impaired verbal communication related to residual aphasia secondary to loss of
neuronal function responsible for speech.
3. Impaired urinary elimination pattern related to decreased impulse to void and
inability to reach the toilet for voiding
Potential nursing diagnosis:
Risk for impaired skin integrity related to limited mobility.

Nursing care plan: 1

1. Impaired physical mobility related to neuro-muscular dysfunction and
decreased muscle strength and control related to neuronal dysfunction caused
by decreased cerebral perfusion.
.
Assessment Nursing Expected Plan of Implementations Rationales Evaluat
diagnosis outcome action ion
Subjective: Ineffective Patient Assess the Respiratory To obtain My
Patient states airway will respiratory status (rate, baseline goal
that “he feels clearance achieve status (rate, pattern, breathe was
data.
the sputum related to clear throat pattern, sound, oxygen
stuck in the copious and normal breathe saturation) also met as
airway and tracheobronchia breathing sound, BP, pulse and patient
makes l secretions as pattern oxygen temperature was was
difficulty in evidenced by within my saturation) assessed and able to
breathing.” sputum shift. also BP, pulse following were remove
production and and the values.
cough. temperature. BP: the
Objective:
On 120/80mmHg secretio
assessment Pulse:80b/m ns and
wheezing Reparatory rate: saturati
sound was 24b/m on was
present and SPO2:84 % in
SPO2 level N/P at 4ltmlin also
84% with O2 O2 92%at
at 2 liter per 4lt O2.
minute. Auscultate Lung’s sound
lungs sound was auscultated Abnormal
and found out to breath
have a presence sounds can
be heard as

of wheezing fluid and

sound. mucus
accumulate.
This may
indicate
airway is
obstructed.

Humidified Increasing
Maintain oxygen humidity of
humidified increased to 4 inspired air
oxygen and liters per will reduce
increases the minutes via thickness of
oxygen nasal cannula. secretions
supply. and aid their
removal.
Deep breathing
Teach deep and coughing Helps to
breathing and loosen the
exercise was
coughing sticky
exercise. taught. mucus
secretions.
 Coordinate Includes the
with a Chest techniques to
physiotherapi physiotherapy mobilize
st to provide was provided secretions
chest physio. with spirometry. from smaller
airways that
cannot be
eliminated by
means of
coughing or
suctioning.
Encourage Movement and It helps to
movement positioning was mobilize
and propped secretions
encouraged.
up and propped
positioning. up position
helps to
promote
better lung
expansion
and improve
air exchange.

Administer Bronchodilators It facilitates

bronchodilat and nebulizer is airway
ors and clearance
administered as
nebulizer as and
prescribed. prescribed. bronchial
dilation by
relaxing the
smooth
muscles.

Encourage Fluid intake was Fluid intake

for fluid encouraged. helps in
intake thinning
secretions.

Nursing care plan: 2

Hyperthermia related to infection and inflammationof lung parenchyma as
evidenced by increased body temperature.
Assessment Nursing Expected Plan of Implementatio Rationales Evaluation
diagnosis outcome action ns

Subjective Hypertherm Patient’s Asses the Vital signs of It helps to obtain My goal
data: “I ia related to temperature patient was
vital signs baseline data. was fully
infection will be assessed and met as
have a of patient
reduced to was: patient
fever and and especiallyBP:110/70mm
normal temperatur
feel inflammatio within my temperaturHg e was
fatigue” n as shift. e. Pulse: 108b/m reduced
evidenced Respiration : within
by increased 24b/m normal
Objective:
Temp : 38.2°c range that
Flushed body SPO2: 95% at is 36.2°c
skin, warm temperature. RA within my
to touch Provide Luke warm shift.
and Luke warm water was It helps in
water provided for reducing temp by
temperature evaporation.
sponge sponging.
was raised baths and
to

38.2degree avoid ice

Celsius. water.

Adjust and Adjusted and Room and

monitor monitored blankets/linen
environme environmental /clothes may be
ntal factors factors like adjusted to
room temp, regulate temp. of
like room excess clothing patient.
temp, and blanket
remove removed.
excess
clothing,
blankets.

Encourage Fluid intake It helps to

patient to was replace fluid loss.
increase encouraged.
fluid intake
 Administer Antipyretics
antipyretics was
administered.
Tab
paracetamol
500mg P/O Antipyretics ca
was given. use the
hypothalamus to
override an
interleukininduce
d
increase in
temperature. The
body will then
work to lower the
temperature and
the result is a
reduction in fever

Nursing care plan:3

Activity intolerance related to compromised pulmonary function and
generalized weakness as evidenced by limited mobility.
Assessment Nursing Expected Plan of Implementation Rationales Evaluation
diagnosis outcome action
Subjective Activity Patient’s Assess vital Vital signs Provide Goal was
data: “I intolerance tolerance to signs. were assessed baseline data. partially
have related to activity will be and it was: met as
difficulty compromised increased BP: 90/50 patient’s
in pulmonary within mmHg tolerance
going to function and hospitalization. RR: 22b/m to activity
toilet, generalized Pulse : 70b/m was
coming out weakness. SPO2 : 90% in increased
of bed.” RA for short
Temp: 36.2°c period only.
Objective
data: patient
seems and Assess the Assessed the Provides
fatigue physical physical baseline
lethargic. activity activity level information
level and and mobility for
mobility of of the patient. formulating
the patient. nursing goals
during goal
setting.
Evaluate the Evaluated the Coordinated
need for need for efforts are
additional additional help more
help at at home. meaningful
home. and effective
in assisting
the patient in
conserving
energy.

Patient was Helps in

Have the encouraged to increasing the
patient perform the tolerance for
perform the activity more the activity.
activity slowly, in a
more slowly. longer time
with more rest
or pauses, or
 with assistance
if necessary.

Gradually Activity was Gradual

increase gradually progression
activity with increased with of the activity
active range- active range of prevents
of-motion motion overexertion.
exercise. exercises in
bed, increasing
to sitting and
then standing.

Avoid Patient was Patient with

performing advised to limited
nonessential avoid activity
activities or nonessential tolerance
procedures. activities. need to
prioritize
important
tasks first.

Encourage Visitor was Assisting the

visitor to encouraged to patient with
assist patient assist patient in self-care
in self-care self-care activities
activities. activities such allows
as eating, conservation
toileting, of energy.
ambulation.

Encourage Encouraged the It helps to

the patient to patient to take gain energy
take nutritious food to perform
nutritious and fluids. activities.
food and
fluids

Reassess the Reassessed the To modify

condition of condition of nursing
patient. patient intervention
as needed.

DEMOGRAPHIC DATA
Name Thuli Kanchi Tamang
Age 82 years
Sex female
Hospital No. 79018192
Bed No. 7D
Address Panchkhal
Ward Medicine ward
Admission date 2023/06/12
Diagnosis Paroxymal Supraventricular Tachycardia(PSVT)

Chief complaints
Palpitation since 1 year but recent since 1 day.
Dizziness on/off.
Throbbing sensation of abdomen rarely.
Actual problem:
Ineffective tissue perfusion
Anxiety
Knowledge deficiet
Potential problem:
Risk for decreased cardiac output.
Actual nursing diagnosis
Ineffective tissue perfusion related to impaired blood flow due to rapid heart rate as evidenced
by decreased saturation level upto 80%
Anxiety related to altered health state as evidenced by fear of palpitations.
Knowledge deficit related to disease condition as evidenced by frequent questioning by patient
and visitor.
Potential nursing diagnosis:
Risk for decreased cardiac output related to decrease ventricular filling.

Nursing care plan: 4

Ineffective tissue perfusion related to impaired blood flow due to rapid heart
rate as evidenced by decreased saturation level upto 80%
Assessment Nursing Expected Plan of action Implementation Rationales Evaluation
diagnosis outcome
Subjective Ineffective Patient will Vital signs was My goal was
data: “I tissue be able to Assess the assessed To obtain completely
have perfusion breath vital signs and found baseline data. met as
shortness of related to normally to be: patient’s
breath and impaired within my BP:100/60mmHg SOB
difficulty in blood shift. Pulse :115b/m resolved and
breathing.” flow due RR: 24b/m saturation
to rapid SPO2 : 80%at RA was raised
Objective heart rate upto 98% in
data: patient as 2lt o2.
Assess the Assessed the Pallor,
seems evidenced
colour , colour , sensation cyanosis, or
restless and by
decreased sensation of all of all extrimites. mottled skin
saturation is
saturation extrimites. There was no color indicate
dropped to
level upto cyanosis present. a blockage in
80%
80% perfusion to
the extremity.

Proper Patient was It enhances

positioning of placed in semi the blood
patient for fowler’s position. flow to the
optimal vital organ.
perfusion.

Provide Supplement
oxygen Oxygen therapy
was provided via oxygen can
therapy as improve the
needed. Nasal prongs at
4lit/min. oxygenation,
enhancing the
tissue
perfusion.
Proper
hydration
ensures
adequate
blood volume,
supporting
Maintain the Adequate optimal tissue
adequate hydration was perfusion.
hydration. maintained as
patient was
encouraged to
drinks fluids and
monitoring of
intake output
chat was done.
 Nursing care plan: 5
Knowledge deficit related to disease condition as evidenced by frequent
questioning by patient and visitor.
Assessment Nursing Expected Plan of action Implementations Rationales Evaluation
diagnosis outcome
Subjective Knowledge After my Assess the Knowledge To collect and
My objective
data: “I deficit nursing level of level of patient identify the
was fully met
want know related to intervention, knowledge of about his as the patient
baseline data.
about my disease patient’s patient about disease was verbalized
disease condition and visitor’s her disease assessed. her
condition.” as knowledge condition. understandin
evidenced about her g of her
Objective by frequent disease Explain To provide disease
data: questioning condition about the risk information condition.
Patient and by patient will be factor and the Explained about regarding the
visitor and visitor. improved. clinical the risk factor risk factor and
seemed features and the clinical symptom.
anxious of features of
and was PSVT. PSVT.
frequently
asking
question Explain the Explained the To identify
about patient party patient party patient party
disease. regarding regarding reaction on
various various various type
laboratory laboratory of laboratory
investigations investigations investigations
required for required for done in ward.
diagnosis of diagnosis of
PSVT PSVT

Explain about Treatment It helps to

treatment modalities reduce the
modalities. was anxiety level
explained. and develop
faith in
treatment.

Warn patient Patient was

about the warned about To reduce
consequences consequences severity and
and and recurrent
complication complications of chance of
ischemic
 that can occur skipping attack.
if medication medication.
is skip.

Advise patient Patient was To reduce the

about the advised about severity of
benefits of the benefits of transient
regular health regular health ischemic attack
checkup. check-up for as well as to
early prevention. decrease the
risk of
complications.

Assess the Assessed level To find out the

level of of knowledge of effectiveness
knowledge of patient and of my
patient and visitor teaching. informal
visitor after teaching.
teaching.

Nursing care plan: 6

Risk for decreased cardiac output related to inadequate ventricular filling and
rapid heart rate.
Plan of action Rationales Evaluation
Assessme Nursing Expected Implementati
nt diagnosis outcome ons
Subjective Risk for After my My goal
Advise the patient Regular
data: “I decreased nursing Vital signs was met as
and visitors to monitoring of
have feeling cardiac intervention, including heart my patient
monitor the vital the cardiac
of output patient will rate, rhythm, understand
signs regularly status helps to
palpitation related to be able to and BP and her risk of
including heart detect any
since 1 inadequate understand oxygen decreased
rate, rhythm,BP changes or
year” ventricular the risk of saturation was cardiac
and oxygen deterioration in
filling and decreased advised to output, also
saturation. cardiac
Objective rapid heart cardiac monitor ready to
rate. regularly. function, follow all
data: output and
allowing for the
Her heart also follow
early necessary
rate was the
intervention. instructions
above 100 instructions
beats per as given to Patient was Chest pain or for keeping
min and decrease the advised to note chest healthy
ECG also risk. chest pain. discomfort heart and
Advise patient to the
showed Identify generally
note chest pain. underlying
tachycardia. location, suggests myoca
Identify location, cause was
radiati on, rdial ischemia
radiation, severity, also
severity, or inadequate
quality, duration,
quality, blood supply to determined.
associated
duration, the heart,
manifestations
associated which can
such as nausea,
manifestations compromise
and precipitating
such as nausea, cardiac output
and relieving
factors. and
precipitating
and relieving
factors.
Encourage the Physical
patient for activity and
Patient was
physical mobility mobility can
encouraged for
within the enhance venous
physical
patient’s tolerance. return, improve
mobility
cardiac
within her
function and
tolerance.
optimize

ventricular
filling.
To instruct patient
on necessary Patient was It helps in
testing. instructed for determining the
necessary cause of
testing as tachycardia.
ordered.
 It helps in
To advice patient Patient and reducing risk of
and visitors for visitors were frequent
timely medication advised for tachycardia and
and proper dietary timely helps in
intake i.e low salt, medication and keeping heart
low fat diet. proper dietary muscle healthy.
intake.