ASSESSMENT NURSING INFERENC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS E
Subjective: After the rotation  to avoid  Improved
 Acute pain Hypertension and nursing  Proper contractur mobility
> Chest pain related to interventions. The positioning es,
>Headache hemiplegia Occlusion patient should: reliever  Absence of
>Dyspnea and disuse within vessels  Apply splint pressures, shoulder pain
>Dizziness of the brain  Improve at night attain
parenchyma mobility good body  No signs of
 Place a alignment complication
Disruption of  Avoidance pillow in the , and s
Objective: blood supply of shoulder axilla prevent
in the brain pain compressi  Self-care
 (+) General area  Select ve achieved
body suitable self- neuropath
weakness Tissue and cell  Absence of care ies.
necrosis complicatio activities
 Inability to
ns that can be  to avoid
perform
Destruction of carried out flexion of
gross/fine
neuromuscular  Enhancing with one the
motor skills
junctions self-care hand affected
 Change in
extremity.
level of Interruption in
consciousnes transportation  To avoid
s or of electrical the
responsivenes impulses to adduction
s the of the
 Not neuromuscular affected
appropriate receptors shoulder
physical
grooming HEMIPLEGIA  To
promote
confidenc
e and
participati
on in
caring for
themselve
s as much
as
possible
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTI RATIONALE EVALUATION
DIAGNOSIS ON
Subjective:  impaired verbal Acute After the rotation  Maintain  allow  Achieved
communication hydrocephaly and nursing patient’s the a form of
> Chest pain due to brain interventions. The attention patient communic
> headache damage Increased patient should: when time to ation
>Dyspnea intracranial talking process
>Dizziness pressure  Achieving with the  manage  Relieved
a form of patient, ment for the
Objective: Brain edema communi speak sensory sensory
cation to slowly, difficulti and
 (+) General Dislocation of enhance and give es perceptua
body brain structures verbal one  to avoid l
weakness brainstem activity instructi contract deprivatio
 Inability to compression  Relief on at a ures, n
perform sensory time or reliever
Haematoma and visit a pressure  No signs
gross/fine
resolution perceptua speech s, attain of
motor skills
occurs in 4-8 l therapist good complicati
 Change in
weeks, leaving deprivatio  Approac body ons
level of
a cystic cavity n h patient alignme
consciousness
 Absence with a nt, and  Improved
or of decrease prevent mobility
responsiveness complicat d field of compres
 (+) blood flow ions vision on sive
problem in the  Improve the side neuropa
brain mobility where thies.
 (+) bleeding in visual
the brain (CT percepti
Scan) on is
 (+) paralysis intact
of left side of  Proper
the body positioni
ng