ASSESSMENT Subjective Masakit yung opera sa akin Objective Facial Grimace Guarding behaviour over incision site BP=130/90mmHg

mHg PR=70 bpm regular and equal in strength bilaterally RR=20 cpm regular and bilateral equal chest expansion Temp=35.8 C

NURSING DIAGNOSIS Acute pain r/t post-operative surgical incision secondary to parotidectomy

PLANNING Short Term Objective: Within the shift, the pt will verbalize decrease of pain felt in incision site from 3/10 to 2-1/10 scale. Long Term Objective: After 3-6 days of NI, pt will report diminished pain with a scale of 0/10

INTERVENTIONS Establish therapeutic relationship Monitor v/s Assess pts general condition

RATIONALE To gain pt and SOs trust and cooperation To obtain baseline data To note for the etiology or precipitating factors that can aggravate the risk. To have a baseline data regarding input and output To maintain hydration status .

EXPECTED OUTCOME The pt shall have took actions regarding minimizing the risk

The pt shall have been free from risk.

Monitor I&O

Encourage increase OFI to al least 2-3 liters per day Arrange bed linens Encourage and assist client to active and passive ROM exercises Encourage rest opportunities

To prevent increase pressure To maintain blood flow

Provided comfort measures and safety Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on all at-risk surfaces.

To promote optimum level of functioning

Assist client in changing positions every two hours Provided Health information regarding the occurring problem Provided conducive environment for resting Encourage client to have balanced diet especially with increased intake of vitamin C and Protein. Monitor and Regulate IVF as per doctors order

To let pt feel safe and comfortable

To maintain skin moisture

To prevent pressure ulcer

To lessen the pts feeling of anxiety

To promote rest and pts wellness

To promote adequate nourishment.

For proper replacement of

fluid losses.

Assessment OBJECTIVE Difficulty in producing speech (+) cough with thick secretions (+) left sided weakness, with limited ROM on upper and lower extremities Nonambulatory Bedridden for 10 days BP=120/90mmH g PR=85 bpm regular and equal in strength bilaterally RR=20 cpm regular and bilateral equal chest expansion Temp=38.3 C(Fever)

Nursing Dx Impaired verbal communicatio n related to loss of oral muscle tone control.

RATIONALE A CVD, which may be caused by, hemorrhage, thrombus, embolism or vasospasm, can result in a local area of cell death, called infarct. It is caused by a lack of blood supply which is then surrounded by an area of cells that are secondarily affected. Since symptoms depend on the location of the stroke and size of the infarct, it could involve the brains Broccas area, which is primary responsible for communication through facial expressions and speech. By causing damage to this area, the patients

Goals After 2 hours of nursing interventions, the client will establish method of communication in which needs can be expressed. As evidence by: Established eye contact while communicating with others Used paper and pen to express needs

Intervention >Monitored vital signs with emphasis to BP.

Rationale >Establishes baseline data for review of existing conditions. >Impaired ability to communicate spontaneously is frustrating and embarrassing. Nursing actions should focus on decreasing the tension and conveying an understanding of how difficult the situation must be for the client

>Provided an atmosphere of acceptance and privacy through speaking slowly and in a normal tone, not forcing the client to communicate.

Evaluation After 2 hours of nursing intervention the goal was met the client established method of communication in which needs are expressed As evidenced by : Established eye contact while communicating with others Used paper and pen to express needs

>Taught techniques to improve speech by initially asking questions that client can answer with a yes or no.

>Deliberate actions can be taken to improve speech. As the clients speech improves, his confidence will increase and she will make more attempts at speaking. >Improving the

communicating skills are greatly altered and affected.

(MedicalSurgical Nursing, vol.2,9th edition, Brunner & Suddarths, page 1259 )

>Used strategies to improve the clients comprehension by using touch and behavior to communicate calmness and adding other non verbal methods of communication such as pointing or using flash cards for basic needs; using pantomime; or using paper and pen. >Involved the significant others in the plan of care.

clients comprehension can help to decrease frustration and increase trust. Clients with aphasia can correctly interpret tone of voice.

>Enhances participation and commitment to plan.

>Educated relatives to establish a method of communication through sign language.

>Imparts thought and answers the needs of the client with lessened difficulty. (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 565)

ASSESSMENT S= 0 The patient manifested the following: O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter, pallor, cold skin, physical immobility.

NURSING DIAGNOSIS Risk for Impaired skin integrity

SCIENTIFIC EXPLANATION The skin is the baseline defense of the body against infection. Any break in the skin may harbor microorganisms that may invade the normal processing of the body, which may inflict or aggravate the pts disease condition.

PLANNING Short Term Objective: After 4 hr of nursing intervention the pt will take actions regarding minimizing the risk

INTERVENTIONS Establish therapeutic relationship Monitor v/s Assess pts general condition

RATIONALE To gain pt and SOs trust and cooperation To obtain baseline data To note for the etiology or precipitating factors that can aggravate the risk. To have a baseline data regarding input and output To maintain hydration status .

EXPECTED OUTCOME The pt shall have took actions regarding minimizing the risk

The pt shall have been free from risk.

Long Term Objective: After 3 days of NI, pt will be free of the risk.

Monitor I&O

Encourage increase OFI to al least 2-3 liters per day

Arrange bed linens Encourage and assist client to active and passive ROM exercises Encourage rest opportunities

To prevent increase pressure To maintain blood flow

To promote optimum level of functioning

Provided comfort measures and safety Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on all at-risk surfaces. Assist client in changing positions every two hours Provided Health information regarding the occurring problem Provided

To let pt feel safe and comfortable

To maintain skin moisture

To prevent pressure ulcer

To lessen the pts feeling of anxiety

To promote rest

conducive environment for resting Encourage client to have balanced diet especially with increased intake of vitamin C and Protein. Monitor and Regulate IVF as per doctors order

and pts wellness

To promote adequate nourishment.

For proper replacement of fluid losses.

ASSESSMENT OBJECTIVE Difficulty in producing speech (+) cough with thick secretions (+) left sided weakness, with limited ROM on upper and lower extremities Non-

NURSING DIAGNOSIS Risk for Injury r/t altered mobility secondary to CVD

SCIENTIFIC EXPLANATION Because of limited range of motion and slightly paralyze body the patient is unable to mobilize properly which maybe a risk for injury.

PLANNING Short Term Objective: After 2 hr of nursing intervention the pt will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury

INTERVENTIONS >Establish rapport

RATIONALE >To gain pt and SOs trust and cooperation >To obtain baseline data >To note for the etiology or precipitating factors that can lead to fever. >that may result

EVALUATION Short Term Objective: The patient shall have demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from injury

>Monitor v/s >Assess pts general condition

>Assess mood,

Long Term

ambulatory Bedridden for 10 days BP=120/90mm Hg PR=85 bpm regular and equal in strength bilaterally RR=20 cpm regular and bilateral equal chest expansion Temp=38.3 C(Fever)

Long Term Objective: After 2 days of NI, pt will be free of injury

coping abilities, personality styles

in carelessness and increased risk taking without considerations of consequences >To promote safe physical environment and individual safety >To enhance self esteem. sense of worth

Objective: The patient shall have been free of injury.

>Identify interventions and safety devices

>Encourage participation in self-help programs, such as assertiveness training, positive self image >raise the side rails of the bed

>To promote safe physical environment and individual safety > To assess if there is presence of pressure ulcers. >To promote safety and easy scanning of the environment. >To prevent injury due to slipping, and to promote safety.

>Frequent skin inspection

>Use effective lighting

>Remind client to walk slowly

>Keep things into right premises and clear the way going to the restroom

>To prevent injury and promote safety.

ASSESSMENT OBJECTIVE Difficulty in producing speech (+) cough with thick secretions (+) left sided weakness, with limited ROM on upper and lower extremities Nonambulatory

NURSING DIAGNOSIS impaired verbal and/or written communication r/t impaired cerebral circulation

SCIENTIFIC EXPLANATION There is an affectation of the certain brain lobes that caused by impaired cerebral circulation that affects its proper functions that leads to decreased, delayed or absent ability to receive, process, transmit and use a system o symbols in communicating resulting in impaired verbal communication.

PLANNING Short Term Objective: After 3 hrs of nsg int. the pt will be able to verbalize or indicate understanding of the communication difficulty and plans for ways of handling.

INTERVENTION S Establish rapport

RATIONALE To gain pts therapeutic relationship To obtain baseline data To note for the etiology or precipitating factors that can lead to fever. To assess causative/contrib

Monitor v/s Assess pts general condition

EXPECTED OUTCOME Short Term Objective: After the nrsing intervention the pt shall verbalize ir indicate understanding of communication difficulty and plans for ways of handling

Long Term

Note results of neurological

Long Term

 Bedridden for 10 days BP=120/90mm Hg PR=85 bpm regular and equal in strength bilaterally RR=20 cpm regular and bilateral equal chest expansion Temp=38.3 C(Fever)

Objective: After 3 days of nursing intervention the pt will establish method of communication in which needs can be expressed.

testing such as EEG/CTscan and the likes Assess environment factors that may affect ability to communicate Establish relationship with the client , listening carefully and attending to clients verbal/nonverbal expressions Maintain a calm, unhurried manner, provide sufficient time for the client to responds Anticipate needs until effective communication is reestablished Administer due meds

uting factors

To assess causative/contrib uting factors

Objective: After the nursing intervention the pt shall be albe to establish methods of communication in which can be expressed.

To assist client to establish a means of communication to express needs, wants, ideas and questions

Individuals may talk more easily when they are rested and relaxed To attend pts needs immediately For pts recovery and to treat underlying conditions RATIONALE

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

INTERVENTION S

EXPECTED OUTCOME

S= 0 The patient manifested the following: O= w/ pale palpebral conjunctiva, w/ pale nail beds, w/ capillary refill time, <3sec. pt. is able to feel deep touch, raise his right arm and leg, w/ slurred speech, w/ left sided weakness, with limited ROM on upper and lower extremities, afebrile, (-) DOB, (-) chest pain.

Impaired Physical Mobility R/t neuromuscular involvement secondary to CVA infarct .

The nervous system is made up of nerve cells called neurons that serve as the communication system of the body. They carry messages in the form of electrical impulses. The messages move from one neuron to another to keep the body functioning. Because neurons have, limited ability to repair themselves unlike other body tissues that is why nerve cells cannot be repaired if damaged due to injury or disease.

Short Term Objective: After 4 hrs. Of Nursing Intervention, the pt. will be able to maintain increased strength and function of affected or compensatory part.

>Establish Rapport

> To gain pts therapeutic relationship > To identify any other deviations from normal. >To determine any other underlying cause of manifestations > To prevent further stress & fatigue

>Monitor Vital signs >Assess patient condition

The patient may also manifest he following: >Slowed movement, >Postural instability during performance of ADLs >Movement induced shortness of breath.

Long Term Objective: After 2-3 days of nursing intervention, the pt. will be able to demonstrate behaviors that enable resumption of activities.

>Provide adequate rest periods as well as comfort & safety measures >Turn pt. slowly from side to side

Short Term Objective: After 4 hrs. Of Nursing Intervention, the pt. shall be able to maintain increased strength and function of affected or compensatory part.

> To provide proper circulation of blood flow on both sides >To assess functional ability >To promote optimal level of function >Promotes wellbeing and maximizes energy production. >To assist in learning ways of managing problems of

>Determine pt. level of mobility >Assist pt. in his activities

Long Term Objective: After 2-3 days of nursing intervention, the pt. shall be able to demonstrate behaviors that enable resumption of activities.

>Encourage adequate intake of fluids & Nutritious foods >Involve clients SO in care

immobility.