NURSING CARE PLAN

CUES
Subjective Cues: The significant other stated that the client complained of numbness of the right leg after standing abruptly and that is when they rushed her to the emergency room. Objective Cues: Generalized weakness. Altered muscle strength and control of affected area. Inability to perform activities of daily living: - Eat - Bathe - dress up, - toilet task

NURSING DIAGNOSIS Self-care deficit related to neuromuscular impairment and weakness.

ANALYSIS
Self care deficit impaired ability to perform or complete task like feeding, bathing/hygiene, dressing and grooming, or toileting activities of oneself. *Cerebrovascular disease (CVA) or stroke referes to any physical or structural abnormanilty of the brain caused by a pathological condition of the cerebral vessels or the entire cerebrovascular system. This pathology either causes hemorrhage from a tear of vessel wall or impairs the cerebral sirculation by a partial or complete occlusion of the vessel lumen with transient or permanent effects.

GOAL AND OBJECTIVES

Goal: At the end of the shift, the client will be able to perform self-care activities within level of own ability. Objectives: After 8 hours of nursing interventions: Assess disease severity/ functional ability.

NURSING INTERVENTIONS

RATIONALE

EVALUATION
Effectiveness: At the end of the shift, was the client able to perform self-care activities within level of own ability? ___Yes ___No, Why?

Assess clients muscle strength, gross and fine motor coordination.

To identify/note probable management/plan of care, severity of the condition. To identify plan of care; to know clients needs for assistance (weaknesses). Reestablishes sense of independence and fosters self-worth, selfesteem and enhances rehabilitation process.

Determine individual strengths and skills of the client.

Efficiency: Were resources of the nurse and patient efficient and able to maximize? ___Yes ___No, Why?

To assist in correcting/dealing with situation.

Avoid doing things for patient can do for self, as well as encouraging significant others to allow patient to do as much as possible, but provide assistance as necessary. Provide self-help devices, eg: knife-spoonfork combination, longhandled brushes, extensions to pick up

Appropriateness: Were all the interventions to the client are appropriate for him to attain the desired goal? ___Yes ___No, Why? Acceptability: Were all the interventions to the client are

Enables patient to manage for self, enhancing independence and selfesteem; reduces

*classic symptoms includes altered muscle tone, weakness, easily getting tired, difficulty of activities and paralysis which he/she may not do certain things for himself like the activities of daily living which is vital for living. Clients with CVA, specifically paralysis cannot do things all by himself (self-care deficit). Reference: (*Doenges, Marilynn E. et al, Nursing Care Plans, guidelines for individualizing th patient care 11 Edition page 227) (*www.MayoClinic .com) (*Dr. Wagman, Medical and Health Encyclopedia volume 2 page 380)

things on the floor, encourage and assist with eating, bathing/hygiene, grooming, dressing up. Assess ability to communicate the need to void and/or ability to use urinal/bedpan. Encourage/assist to the bathroom at frequent intervals as appropriate.

reliance on others for meeting own needs. And enables to be socially active.

acceptable for him? ___Yes ___No, Why? Adequacy: Were the interventions adequate for him to attain the desired goal? ___Yes ___No, Why?

Patient may have neurogenic bladder, may be unable to communicate needs in acute recovery; but as recovery progresses, independence will be regained. Assist in development of retraining program and aids in preventing constipation and impaction (long-term effects). Patients may need empathy and to know caregivers will be consistent in their assistance. Enhances sense of selfworth, promotes independence, and encourages patients to continue endeavors.

Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet, encourage fluids, increased activity. Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks.

Provide positive feedback for efforts and accomplishments.

(Reference: Doenges, Marilynn E. et al, Nursing Care Plans, guidelines for individualizing patient care th 11 Edition page 238-239)