DIVINE WORD COLLEGE OF SAN JOSE

NURSING DEPARTMENT
NURSING CARE PLAN
Name: C.G. Medical Diagnosis:CVA
Age: 63 Attending Physician: DR. Francisco
Address: Caminawit, San Jose Chief Complaint: Chest Pain

NURSING ANALYSIS GOAL & INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES
Ineffective tissue Decrease in oxygen GOAL
perfusion related to resulting in the After series of nursing Goal unmet.
impaired transport failure to nourish interventions, the patient Patient needs more seek
of oxygen secondary the tissues at the will demonstrate increased from doctors and more
to cerebro vascular capillary level. perfusion. advanced technologies in
accident determining her condition.
NANDA
I= “kadalasan OBJECTIVES:
sumasakit ang dibdib
ko” After 8 hours of nursing
interventions the patient
O= pale & weak will:
Dyspnea
Left hemiparesis  Demonstrate  Establish rapport to the  To have their full
Difficulty of behaviors/lifest client and significant cooperation
swallowing yles changes to others
M= T=37.1 improve  Monitor and record vital  To have baseline data
P=72 circulation signs
R=18  Monitor and record I &  To determine fluid
BP= 150/90 O volume relative to
oxygen transportation
and circulation
  Elevate head of bed  To promote circulation
 maximize  Conserves energy
tissue perfusion  Encourage quiet and lowers tissue oxygen
restful atmoshphere demands.
 To prevent from
 Encourage increase dehydratrion
fluid intake
 To compensate the
 Administer oxygen to demand of oxygen
the client needed by the body

 Instruct patient on
preventing shoulder
adduction

 Encouraged patient to
frequently change
position of hands and
fingers
 promote  To promote circulation
wellnes  Advised client to
exercise and provide
ROM  To decrease tension
level
 Demonstrate use of
relaxation techniques

 Maintain body
alignment in functional
position

 Exercise affected limb

 Assist and provide
comfort measures to the
patient

 Instruct patient to place

food on the unaffected
side of the mouth