NURSING CARE PLAN

INEFFECTIVE CEREBRAL TISSUE PERFUSION Assessment Subjective: May mga oras na nahihilo sya, as verbalized by patients wife. Diagnosis Ineffective Cerebral Tissue Perfusion related to occlusion of vessel secondary to infarction. Goal After rendering nursing intervention, the cerebral perfusion pressure will be maintained as to the stability of the Objective: Hemiparesis GCS of 6 out of 15 upon admission vital signs within the clients normal range. Objective After rendering nursing intervention, the patient will be able to: a. Manifest increased perfusion as individually appropriate to the patients condition. b. Demonstrate ways of understanding of condition, therapy regimen, side
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Intervention Independent: 1. Monitor and record neurological status, particularly Glasgow Coma Score.

Rationale Monitor to determine effects of stroke and prevent lifethreatening complications such as severe hypertension

Evaluation Goal partially met. After rendering nursing intervention, the patients cerebral perfusion is not adequately maintained however the

and intracranial patient pressure. 2. Assess past history of systemic problems: previous To monitor patients condition. established stability of the vital signs within the clients normal range.

effects of medication and when to contact health care provider together with his family.

cardiac disease and hypertension. 3. Monitor vital signs as needed. Because of cerebral edema, fluid balance will be regulated. 4. Monitor intake and output. To diminish perfusion, ICP should be below 15 mmHg. 5. Raise the head of the bed. Cerebral perfusion should be between 80 to 100 mmHg. 6. Keep head and neck in neutral To eliminate the need to impinge blood

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position.

vessels and circulation. To have good peripheral especially cerebral circulation.

7. Assist the patient to limited passive ROM exercises.

Dependent: 8. Administered due meds. To continue treatment.

Collaborative 1. Review diagnostic studies and laboratory exams. To know other underlying conditions that precipitates the present
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condition of the patient.

IMPAIRED PHYSICAL MOBILITY Assessment Subjective: Nahihirapan syang magkikilos dahil sa hindi nya magalaw ang kanang kamay at paa nya, as verbalized by patients wife. Diagnosis Impaired physical mobility related to restricted perfusion of bundle of nerve fibers as manifested by Goal Objective Intervention Independent: 1. Assess patients degree of weakness in both upper and lower extremities. 2. Assess ability to move and change position, to transfer and walk, for fine muscle movement and gross muscle There may be differing degrees of involvement on the affected side. Paralysis, paresis and sensory loss are contralateral to the side of the brain affected by stroke. Rationale Evaluation Goal partially met. After rendering nursing intervention, the patient cannot maintain level of function and reduces risk of complications.

After rendering After rendering the nursing intervention, the patient will be able to maintain maximum level of function and nursing intervention, the patients family will be able to: a. Verbalize understanding of situation and individual treatment regimen and safety measures.

right hemiplegia reduce risk of complications.

Objective: Scored 0/5 in right side and

b. Demonstrate technique or behaviors that

2/5 in the left side of the body in motor assessment. Scored 0% in the right part of the body and 50% in the left of the body in sensory assessment. Limited range of motion Muscle flaccidity on right part

enable resumption of activities c. Maintain position of function and skin integrity as evidenced by absence of contractures, foot droop and decubitus

movement. 3. Determine active and passive range of motion capabilities. Initially muscles demonstrate hyporeflexia, which later progresses to hypereflexia. 4. Change position of patient at least every 2 hours keeping track of position changes in turning schedule. 5. Perform active and passive range of motion exercises in all extremities several times
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Patients may not feel increases in pressure or have the ability to adjust position. This preserves muscle strength and prevents contractures, especially

daily.

spastic extremities.

Collaborative: 6. Teach patient and family exercises and transfer techniques. Exercise will increase strength, promote use of the affected side, and promote transfer of safety.

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SELF-CARE DEFICIT Assessment Subjective: Hindi nga sya makakain magisa eh kailangan subuan pa. as verbalized by patients wife. Diagnosis Self-care Deficit r/t neuromuscular impairment as manifested by self-feeding deficit and self-toileting deficit Objective: Inability to get food onto utensil Inability to get to toilet With indwelling Foley catheter Goal After rendering nursing intervention, the patient will be productive enough to perform daily activities. Objective After rendering nursing intervention, the patient will be able to: a. Demonstrate Intervention Independent: 1. Provide for communication among those who are involved in caring for/assisting the client. To reduce risk of injury in part of the client. To progressively increase the patients ability to void and move bowel To enhance coordination and Rationale Evaluation Goal not met. After rendering nursing

continuity of care intervention, the client was not able to perform ADL.

lifestyle changes to 2. Provide privacy and meet self-care means b. Perform selfcare activities within level of own ability c. Identify personal or community resources that can provide assistance
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equipment within easy reach during personal care activities. 3. Implement bowel or bladder training/retraining program.

Dependent: 4. Assist with To help promote

medication regimen as necessary, encouraging timely use of medications.

independence in taking medications.

Collaborative: 5. Assist with rehabilitation program. To enhance capabilities or promote independence

DISTURBED SENSORY PERCEPTION Assessment Diagnosis Goal Objective Intervention Rationale Evaluation

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Subjective: Walang nararamdaman ang kanan nyang kamay, ni hindi nya din maigalaw e, as verbalized by patients wife.

Disturbed sensory perception related to stroke within the sensory transmission and integration pathways of the brain

After rendering nursing intervention, the patients skin will remain free of injuries and pressure ulcers.

After rendering nursing intervention, the patient and family will be able to: a. Demonstrate skill in therapeutic interventions. b. Recognize and correct or compensate

Independent: 1. Assess patients ability This determines to sense light touch, pinprick, and temperature. Touch skin lightly with a pin, cotton ball or hot/cold object and ask patient to describe sensation and point to where touch occurred. 2. Perform regular skin inspections and instruct patient in techniques to do the same. Explain consequences of prolonged pressure on the skin. 3. Explain how stimulus might feel.
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Goal met. After rendering nursing intervention, the patients skin is free of injuries and pressure ulcers.

the level of alteration and identifies specific areas of risk.

Pressure on the affected side should last no longer than 30 minutes.

Objective: Change in usual response to stimuli Motor incoordination Change in sensory acuity particularly

for sensory impairments. c. Verbalize awareness of sensory needs and presence of overload/ deprivation.

This improves patients

visual and tactile perception 4. Instruct patient to regularly move affected limbs.

understanding. Movements promote circulation. Impaired sensitivity to pain or numbness increases the likelihood of prolonged stationary positioning.

Collaborative: 5. Enhance the immediate and home environments. For optimum safety, by regulating temperature setting on hot water heater, moving sharp
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edged furniture, and lightning hallways.

CONSTIPATION Assessment Subjective: Yan nga yung nagging problema naming eh 3weeks syang hindi napadumi. Ngayon nalang ulit sya napadumi. as Diagnosis Constipation related to irregular Goal After rendering nursing intervention, the Objective After rendering the patients family will be able to: a. Verbalize understanding of etiology and appropriate
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Intervention Independent:

Rationale To evaluate clients hydration status. To determine the presence of distension

Evaluation Goal partially met. After rendering nursing intervention, after 1 day, the patient defecated.

nursing intervention, 1. Determine fluid intake.

defecation habits patient will be able to regain normal pattern of bowel functioning.

2. Palpate abdomen.

verbalized by patients wife.

interventions or solutions for individual situation. b. Demonstrate 3. Note color, odor, consistency, amount and frequency of stool. 4. Instruct in and encourage a diet of balanced fiber and bulk and fiber supplements. 5. Promote adequate fluid intake, including high-fiber fruit juices; suggest
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or masses. Provides a baseline for comparison, promote changes. To improve consistency of stool and facilitate passage through colon.

Objective: Hard, formed stool Percussed abdominal dullness Frequency of bowel elimination

behaviors or lifestyles changes to prevent presence of problem.

To promote passage of soft stool

drinking warm, stimulating fluids. 6. Encourage activity and exercise within limits of individual ability. 7. Provide privacy and routinely scheduled time for defecation 8. Encourage sitz bath after stools For soothing effect of the rectal area. So client can respond to urge. To stimulate contractions of the intestines

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