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ASSESSMENT Subjective: hindi ako makapagsalita ng maayos as verbalized by the patient.

DIAGNOSIS Impaired verbal communication related to

PLANNING After 1 hr. Of nursing intervention, the patient

INTERVENTION >Anticipate and provide for patients needs.

EVALUATION After 1 hour of nursing intervention, the patient was able to establish

loss of facial or oral muscle will establish method of tone control. communication in which needs can be expressed. >Talk directly to patient.

method of communication in which needs can be

Objective:

>Speak in normal tones and avoid talking too fast.

expressed.

>Difficulty producing speech >Muscle and facial tension > Body weakness >(R) arm weakness

Give patient ample time to respond.

>Use yes or no question to begin with.

>Encourage family members and visitors to persist efforts to communicate with the patient.

ASSESSMENT Objective: (R) Hemiplegia Limited ROM Difficulty turning Slowed movement Movement induced shortness of breath/tremors

DIAGNOSIS Impaired physical mobility related to neuromuscular involvement secondary to CVA infarct

PLANNING Short term: After 4 hours of nursing intervention, patient is willing to participate in activities necessary for the patient. Long term: After 3 days of nursing intervention, patient will be able to improve and increase strength and function of affected body part.

INTERVENTION > Establish rapport >Monitor VS and I &O >Determine readiness to engage in activities/excercises >Assist pt reposition self in a regular schedule. >Provide for safety measures including fall prevention. >Involve pt and SO in care assisting them to learn ways of managing problems of immobility. >Assist pt to do passive range of motion >Provide restful environment for patient after periods of excercise. INTERVENTION >Monitor VS and I &O >Keep the side rails of the bed raised >Place pillow at the patient sides > Keep patient monitored >Stay with patient.

EVALUATION Short term; Patient participated in activities willingly Long term: Pt have improved and increase strength and function of affected body part.

ASSESSMENT Objective: Right hemiplegia

DIAGNOSIS Risk for Injury related to right hemiplegia secondary to CVA infarct

PLANNING After 8 hours of nursing intervention, pt will be able to perform tasks that are beyond his capabilities.

EVALUATION Patient remained free from injury.