Practice Nursing Care Plan

Jeriel Martinez

November 8, 2010
ASSESSMENT DATA:

Mr. A is a 46 year old Hispanic who suffered from a cerebrovascular accident (CVA). He was
admitted because of having a BP of 215/138. He has a history of hypertension and has been non-
compliant with medications in the past. Last vital signs taken showed a BP 162/93, HR 62, T 98.9, RR
18. Pt. does not complain of any pain. Has mild dysarthria, speech is slurred but discernable. Pt. asked if
Proposition 19 passed showing good orientation of place and time. Mild dysphagia present, drooling, has
been placed on soft diet with thin liquids. Complains of left side weakness stating “I can’t use my left
arm or leg,” requires assistance with getting dressed and undressed. Skin is intact with no visible sores or
lesions. Pt shows ability to void in urinal but requires assistance to commode to defecate. Support
system consists of his sister.

NURSING DIAGNOSIS #1:

 Disuse Syndrome r/t paralysis of left limbs s/t CVA a.e.b inability to use left arm and leg; states
“I can’t use my left arm or leg.”

GOAL:
 Pt. will not experience complications caused by immobility of the left limbs for duration of
hospital stay.

INTERVENTIONS:
 Assist patient in moving paralyzed right arm and leg every hour to relieve pressure on bony
prominences reducing the risk of preventing pressure ulcers.
 Perform passive ROM exercises 4 times a day to promote tissue perfusion and flexibility to
affected limbs.
 Instruct patient to use unaffected arm to move affected limbs when possible
 Assess skin integrity every 2 hours.

EVALUATION:
 Pt. has shown no signs of pressure ulcers and is able to shift affected limbs with unaffected arm.
Progressing towards goal.

NURSING DIAGNOSIS #2:

 Impaired Physical Mobility r/t paralysis of left limbs s/t CVA a.e.b compromised ability to
ambulate to restroom.

GOAL:
 Short term - Pt. will demonstrate proper safety precautions in the next 24 hrs such as calling for
help when needing to use the commode.
 Long term - Pt. will be able to independently ambulate in one month.

INTERVENTIONS:
 Teach pt. to use call button when in need of assistance.
 Work with Physical Therapist daily to improve mobility.
 Gradually increase amount of ambulation each day.

EVALUATION:
  Pt. is still unable to ambulate independently and has called for assistance when needing to use the
commode demonstrating proper safety. Short term goal achieved
 Pt. was able to ambulate with 25% less assistance. Progressing towards goal.

NURSING DIAGNOSIS #3:

 Self-Care Deficit: Dressing r/t paralysis of left arm s/t CVA a.e.b inability to put on clothing
without assistance.

GOAL:
 Pt. will demonstrate increased ability to dress self without the need for assistance during hospital
stay.

INTERVENTIONS:
 Encourage pt. to wear looser clothing to facilitate easier dressing and undressing.
 Promote independence by letting pt. dress and undress without assistance and assist only when
necessary.
 Allow extra time for pt. to get dressed so that he does not feel rushed

EVALUATION:
 Pt. showed the ability to put on socks and a loose shirt. Still needs assistance putting on pants.
Progressing towards goal.