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Cva NCP

A patient presented with symptoms of a stroke including slurred speech, body weakness, limited mobility, and uncoordinated movements. The nurse's assessment concluded the diagnosis was paralysis related to damaged motor pathways from a stroke. The nursing care plan was to establish rapport, monitor vital signs, reposition every 2 hours to prevent ulcers, encourage involvement in activities, and perform range of motion exercises to restore mobility and maintain strength. After 4 hours the patient was able to gradually restore movement and understood their treatment plan.

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xiang jin
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887 views1 page

Cva NCP

A patient presented with symptoms of a stroke including slurred speech, body weakness, limited mobility, and uncoordinated movements. The nurse's assessment concluded the diagnosis was paralysis related to damaged motor pathways from a stroke. The nursing care plan was to establish rapport, monitor vital signs, reposition every 2 hours to prevent ulcers, encourage involvement in activities, and perform range of motion exercises to restore mobility and maintain strength. After 4 hours the patient was able to gradually restore movement and understood their treatment plan.

Uploaded by

xiang jin
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN/NCP

Assessment Inference Diagnosis PIanning Intervention RationaIe EvaIuation



Subjective:

"Nahihirapan na
siyang ikilos ang
kanang bahagi ng
kanyang katawan
as verbalized by
the patient's wife.

Objective:

O Vital Signs:
BP: 160/100
Temp: 38.1C
PR: 145
RR: 12
O Slurred speech
O Body weakness
O Weak and pale
looking
O limited ability to
perform gross or
fine motor
movement
O Uncoordinated
or jerky
movements



Vasoconstriction


Blockage of the blood
vessels resulting to
embolism


Lack of oxygen and
nutrients supply resulting
to hypoxia


Altered cerebral
metabolism


| cerebral perfusion


Local acidosis


Cytotoxic edema


Aneurysm rupture


Stroke


Paralysis

mpaired
physical mobility
related to
damaged motor
neuronal
pathway.

After 4 hours of
nursing intervention,
the patient will be
able to gradually
restore physical
mobility as evidenced
by:

Verbalization of
understanding of
situation / risk
factors & individual
treatment regimen
& safety measures

Long Term:
Maintain or
increase strength
and function of
affected body part
or whole body.

Establish rapport with
the patient

Monitor Vital Signs



Reposition client q2



Provide safety
measures including
environmental
management

Encourage patient's
involvement in
activities & decision
making


Perform passive
range of motion
exercises daily


ncrease functional
activities as strength
improves

To gain patient's
trust

To obtain baseline
data and for
comparison

To prevent
development of
pressure ulcers

To reduce risk for
falls and further
injury


Enhances
commitment to plan
and optimizing
outcomes

To preserve muscle
strength and
functional ability

Limits fatigue and
ability to perform
ADLs.

Goal met

After 4 hours of
nursing
intervention, the
patient was able to
gradually restore
physical mobility as
evidenced by:


Verbalized
understanding of
situation / risk
factors & individual
treatment regimen
& safety measures

Maintain or
increased strength
and function of
affected body part
or whole body.

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