NURSING CARE PLAN

Pt name:Mr. RT
Assessment
Subjective:
Client said,
namamanhid yung
kanang kamay ko,
pero nagagalaw ko
naman xha medyo
hirap lng ako.

Nursing Dx
Impaired physical
mobility r/t
neuromuscular damage
involvement
(Right arm numbness) as
evidenced by motor
control

Objective:
Limited range of
motion (client cant
fully extend his right
arm and hold up his
right shoulder)
Limited ability and
difficulty to perform
gross motor skills like
extending and lifting
of the right arms
Unsteady gait
Slowed movement
Right arm numbness

Assessment

Nursing Dx

AGE: 83
Goals

Intervention
Independent:
Long term:
1. Determine degree of immobility
After 4 days of nursing
intervention, client will be able 2. Observe movement when client
is unaware
to physical mobility
3.
Support affected part with
Expected outcome:
pillows
Demonstrate resumption of
4. Give rest periods to activities
activities
5. Encourage adequate fluids and
Participate in ADLs
right diet as necessary to the
Maintain or muscle
client
control
Short term:
After 8 hrs of nursing
intervention, client will be able
to participate in therapeutic
regimen
Expected outcome:
Verbalize understanding of
the situation
Verbalization of
understanding the therapy
Able to participate in the
interventions rendered by
the nurse

Goals

Intervention

DIAGNOSIS: Acute Infact

Rationale
Evaluation
Independent:
Long term goals met:
1. To establish
Client is able to physical
comparative
mobility as evidenced by
baseline
resumption of activities,
2. To note any
participation in his ADLs
incongruenc
and right arm numbness
e with the
reports of
Short term goals met:
abilities
The client is able to
3. Reduce risk
participate on the therapeutic
of pressure
regimen as evidenced by
ulcers
verbalization of
4. To help
understanding of the
reduce
situation, therapy, and he is
fatigue and
able to participate in the
O2 demand
interventions rendered by the
5. energy
nurse
production

Rationale

Evaluation

Subjective:
Client said,
namamanhid yung
kanang kamay ko,
pero nagagalaw ko
naman xha medyo
hirap lng ako.

Impaired physical
mobility r/t
neuromuscular damage
involvement
(Right arm numbness) as
evidenced by motor
control

Objective:
Limited range of
motion (client cant
fully extend his right
arm and hold up his
right shoulder)
Limited ability and
difficulty to perform
gross motor skills like
extending and lifting
of the right arms
Unsteady gait
Slowed movement
Right arm numbness

Assessment

Diagnosis

Long term:
After 4 days of nursing
intervention, client will be able
to physical mobility
Expected outcome:
Demonstrate resumption of
activities
Participate in ADLs
Maintain or muscle
control
Short term:
After 8 hrs of nursing
intervention, client will be able
to participate in therapeutic
regimen
Expected outcome:
Verbalize understanding of
the situation
Verbalization of
understanding the therapy
Able to participate in the
interventions rendered by
the nurse

Planning

Independent:
6. Determine degree of immobility
7. Observe movement when client
is unaware
8. Support affected part with
pillows
9. Give rest periods to activities
10. Encourage adequate fluids and
right diet as necessary to the
client

Implementation

Independent:
6. To establish
comparative
baseline
7. To note any
incongruenc
e with the
reports of
abilities
8. Reduce risk
of pressure
ulcers
9. To help
reduce
fatigue and
O2 demand
10. energy
production

Rationale

Long term goals met:

Client is able to physical
mobility as evidenced by
resumption of activities,
participation in his ADLs
and right arm numbness
Short term goals met:
The client is able to
participate on the therapeutic
regimen as evidenced by
verbalization of
understanding of the
situation, therapy, and he is
able to participate in the
interventions rendered by the
nurse

Evaluation

Subjective
The client
complained of
slight difficulty of
breathing
Objective
- The patient
appears lethargic
-P: 8 am 57 bpm
12 pm 57 bpm
-BP: 8 am 130/70
12 pm 140/80

Ineffective
Cerebral Tissue
Perfusion related
to interruption of
blood flow
secondary to
multiple cerebral
infarctions as
manifested by
altered level of
consciousness,
changes in motor
& sensory
response, and
language deficits

Goal
The client will have
an effective cerebral
tissue perfusion
after 2 to 3 weeks of
proper nursing
intervention

Determine factors related to

individual situation,
decreased cerebral perfusion
and potential for ICP.

Objectives
1. To assess
contributing
factors
2. To note degree
of impairment
3. To maximize
tissue perfusion

-Speech
abnormalities:
slurred speech
-Extremity
weakness; pain
and discomfort on
lower extremities

Monitor and document

neurological status frequently
and compare with baseline.

-Restless; Keeps
on calling out for
his wife and son

Monitor
vital signs noting: Hypertensio
n or hypotension

-facial weakness
Determine the presence of
visual, sensory/motor change,
headache, dizziness, altered
mental status, personality

Influences choice of interventions.

Deterioration in neurological signs
and symptoms or failure to improve
after initial insult may reflect
decreased intracranial adaptive
capacity, which requires that client be
admitted to critical care area for
monitoring of ICP and for specific
therapies geared to maintaining ICP
within a specified range. If the
stroke is evolving, client can
deteriorate quickly and require
repeated assessment and progressive
treatment. If the stroke is
completed, the neurological deficit
is nonprogressive, and treatment is
geared toward rehabilitation and
preventing recurrence.
Assesses trends in LOC and potential
for increased ICP and is useful in
determining location, extent, and
progression or resolution of CNS
damage.
Fluctuations in pressure may occur
because of cerebral pressure or injury
in vasomotor area of the brain.
Hypertension or hypotension may
have been a precipitating factor.
Visual and sensory/motor changes/
involvement indicate safety concerns
and influence the choice of nursing
intervention.

After 2-3
weeks of
nursing
intervention
the client will
be able to
demonstrate
increased
perfusionm(e.g
., vital signs
within normal
range,
alert/oriented,
free of
pain/discomfor
t)

changes
Elevate HOB
Administer medications (e.g.
antihypertensives, diuretics)

To promote circulation/venous
drainage
Some medications may be used to
decrease edema

Maintain bedrest, provide quiet

environment, and restrict
visitors or activities, as
indicated. Provide rest periods
between care activities,
limiting duration of
procedures.

Continual stimulation can increase

ICP. Absolute rest and quiet may be
needed to prevent recurrence of
bleeding, in the case of hemorrhagic
stroke.

Prevent straining at stool or

holding breath.

Valsalvas maneuver increases ICP

and potentiates risk of bleeding.
Reduces hypoxemia.

Administer supplemental
oxygen, as indicated.

Assessment

Nursing Diagnosis

Subjective:
(n/a)

Impaired verbal communication

related to cerebral impairment
as evidenced by slurring

Objective:
Speaks with difficulty
Slurring
Difficulty in forming words or
sentences
Difficulty in expressing thoughts
verbally
Difficulty in comprehending or
maintaining usual communication
pattern
Difficulty in use of facial and body
expressions
Disorientation to person, space and
time
Use of nonverbal cues
Frustration

Planning

Intervention

After 1 hr of nursing
Assess td of impairment
intervention the patient will Evaluate degree of impairment
relate findings of decreased Note parental speech patterns and
frustration with communication
manner of communicating with
child, including gestures
Offer alternative forms of
communication such as:
gestures or actions
o pictures or
drawings
o magic slate
o word board
o flash cards that
translate
words/phrases
Encourage s/o to participate.
Validate patient's message by
repeating aloud
Use short repetitive directions.
Ask simple yes or no questions
Speak on an adult level, speaking
clearly and slower than normal
Assess frustration level. Wait 30
seconds before providing patient
with word.
Initiate health teaching

Evaluation
After 1 hr of nursing
interventions, the patient was
able to establish method of
communication in which needs
can be expressed

Problem: Self Care Deficit RT Musculoskeletal Impairment

Scientific
Planning
Interventions

Assessment

Nursing

Subjective:

Diagnosis
Self Care Deficit

Explanation
Motor deficit are

Short Term:

(none)

R/t

the most obvious

After 4 hrs of

musculoskeletal

effect of stroke.

NI, pt will be

Objective:

impairment

Symptoms are

able to

with soiled
clothes
with
unsatisfying
appearance
with minimal
sweating
uncombed
hair

secondary to

caused by

identify

CVA

destruction of

personal

motor neurons in

resources

the pyramidal

that can

pathways (nerve

provide

fibers in the brain

assistance

and passing

and be able

through the

to verbalize

spinal cord to the

knowledge of

motor tract.) One

health care

of those

practices.

symptoms could

1. establish rapport
2. monitor vital signs
3. Assess for type
and severity of
immobility
impairment,
muscle flaccidity,
spasticity and
coordination,
ability to walk, sit,
move in bed
perform

Rationale
1. to promote
cooperation
2. to have a baseline
data
3. Provides data
regarding
mobility and
ability to perform
activities with in
limitations
without injury or
frustrations.

Evaluation
Short Term:
Pt shall have
identified
personal
resources
that can
provide

4. passive ROM to all

limbs and progress
to assistive and
then active ROM
in all joints four
times a day

4. promotes
circulation,
muscle tone, joint
flexibility,
prevents
contractures and
weakness

assistance
and be able
to verbalized
knowledge of
health care

5. use assistive
devices as
appropriate for
ambulation,
clothing with
zipper closures,
suction cups on

5. Provides safe
support for
immobility and
other self care
activities to
promote
independence.

practices.

Long Term:

be inability to

Long Term:

perform ADLS.

After 3 days
of NI, pt. will
demonstrate

personal hygiene
articles for
brushing teeth,
combing hair,
clothing that is
easily managed to
dress and undress

Pt shall have
demonstrated
techniques/
lifestyle

techniques/

changes to

lifestyle

meet self-

changes to

care needs

meet selfcare needs

Problem: Activity Intolerance RT Generalized Weakness

Scientific
Planning
Interventions

Assessment

Nursing

Subjective:

Diagnosis
Activity

Explanation
Motor deficits

Short Term:

1. establish rapport

(none)

Intolerance r/t

are the most

After 4 hrs of

2. monitor vital signs

Generalized

obvious effect of

NI, pt will be

3. evaluate current
limitations (degree
of deficit in light
of visual status)

Objective:

weakness

stroke.

able to

right
hemiplegia
increase BP
pt may
manifest:
electro
cardiographic
changes
reflecting
dysrythmias
abnormal
heart rate in
response to
activity
weakness

secondary to

Symptoms are

participate

CVA

caused by the

willingly on

destruction of

necessary/de

motor neurons in

sired

the pyramidal

activities.

pathways (nerve
fibers in the brain

Long Term:

4. assess
cardiopulmonary
response to
physical activity,
changes BP

Rationale
1. to promote
cooperation
2. to have a baseline
data
3. provide
comparative
baseline data

Evaluation
Short Term:
Pt. shall have
participated
willingly in
necessary

4. to note progress
of fatigue

/desired
activities.

5. assist patient with

activities
6. plan care with rest
periods between
activities

5. to protect from
injury
6. to decrease
fatigue

7. increase activity
gradually

7. to manage
activity within
limits
8. assist pt deal with
contributing
factors

Long Term:
Pt shall have

and passing

After 2 days

through the

of NI, patient

spinal cord to

will be able to

motor tract.)

demonstrate

sings of

a decrease in

intolerance

8. encourage
expression of
feelings resulting
from the condition

demonstrated
a decrease in
physiologic

physiologic

(HR,BP

signs of

remains in

intolerance

normal range)

(HR,BP
remain within
normal
range)

Problem: Risk for Unilateral Neglect RT Hemiparesis

Scientific
Planning
Interventions

Assessment

Nursing

Subjective:

Diagnosis
Risk for

Explanation
An ischemic stroke,

Short Term:

(none)

unilateral

cerebrovascular

After 1-2 hrs

neglect r/t

accident (CVA), or

of NI, the pt

Objective:

hemiparesis

brain attack is a

will

slight
irritability
right
hemiplegia
muscle
strength test
of right
arm:0/5; right
leg:o/5; left
arm: 5/5; left
leg:5/5
needs
assistance in
performing
ADLs
decrease
attention to
the affected
side

secondary to

sudden loss of

participate in

CVA

function resulting

the

from disruption of

performance

the blood supply to a

of range of

part of the brain. In

motion

an ischemic brain

exercises on

attack, there is

the

disruption of the

extremities.

1. Established rapport
2. Monitored and
assessed vital signs
3. Assessed patients
general physical
condition
4. Performed AM
care
5. Monitored vital
signs frequently
6. Instructed pt to a
low fat, low salt
diet with SAP
7. Performed muscle
strength test
8. Instructed pt on a
PROM on the right
extremities
9. Promoted adequate
rest

cerebral bloodflow
due to obstruction of

Long Term:

a bloodvessel. This

After 2-3 days

can cause a wide

of NI, the pt

10. Assisted pt with

self-care activities
11. Maintain body
alignment in
functional position
12. Shift pts attention

Rationale

Evaluation

1. To gain trust

Short Term:

2. To obtain
baseline data

The pt shall
have

3. To note for any

abnormality

participated
in the

4. To enhance wellbeing & provide

comfort
5. To note
significant
changes in vital
signs
6. To help reduce
risk of second
attack & prevent
a rise in BP
7. To determine
muscle
functioning on
the extremities
8. To increase
strength and
mobility

performance
of range of
motion
exercises on
the
extremities.

Long Term:
The pt shall
have

variety of neurologic
deficits depending
on the location of the

will increase
the utilization
of the

lesion with which

affected

vessels are

extremities

obstructed. A stroke

with due

is an upper motor

assistance

neuron lesion and

from the SO.

results in loss of
voluntary control
over motor
movements. Because
the upper motor
neurons decussate
(cross), a disturbance
of voluntary motor
control on one side
of the body may

towards the
affected side
13. Administer due
meds

increased the
9. To promote
comfort and
relaxation
10. To prevent injury

utilization of
the affected
extremities

11. To promote and

stimulate
circulation
12. To stimulate and
increase pts
awareness on the
affected side
13. To treat
underlying
medical condition

with due
assistance
from the SO.

reflect damage to the

upper motor neurons
on the opposite side
of the brain. The
most common motor
dysfunction is
hemiplegia
(paralysis on one
side of the body).

1. Ineffective Cerebral Tissue Perfusion

2. Impaired Physical Mobility
3. Impaired Verbal Communication
4. Disturbed Sensory Perception
5. Ineffective Coping
6. Self-Care Deficit
7. Risk for Impaired Swallowing
8. Activity Intolerance
9. Risk for Unilateral Neglect