Ramos, Shelly Mae A.

BSN 3-1 Maam Vine V.

Velasco

Patients Initials : D. E.
Diagnosis: CVA infarct , HPN III
NURSING CARE PLAN

ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTION RATIONALE EVALUATION

D
KNOWLEDGE
S: Activity Infarction on Goal: Obtain initial To gain Goal partially
Hindi na niya Intolerance the left After 1 vital signs baseline data met. After 8
maigalaw ang related to hemisphere month of hrs of nursing
kanang parte neuromuscular has a contra nursing Monitor GCS Note for intervention
ng kanyang impairment lateral intervention increase in the patient
katawan as secondary to manifestation the patient patients was not able
verbalized by Cerebrovascula of either right will functioning to
the patients r Attack. side paralysis demonstrate capability demonstrate
wife and/or increase in Assessed increase level
weakness due physiological General To note for of functioning.
O: to left signs of Condition signs and
-Numbness on hemisphere activity symptoms
the right side affectation tolerance. Provided calm
of the body causing the atmosphere To lessen
-Weak in immobility Objective: patients
appearance because of After 8 hrs agitation
-Aphasia stiffness of of nursing Promoted
-Paleness on muscle and intervention comfort to enhance
extremities inability to the patient measure and ability to
-Initial VS: mobilize due will be able to provide for participate in
BP: to the demonstrate relief of pain activities
140/100mmHg manifestation increase level
PR: 56bpm of the disease of functioning Provided ROM to promote
condition. The from exercises circulation
nervous independent
system is to use of Assisted Reduces risk
made up of personal patient to of tissues
nerve cells assistance. reposition self ischemia,
called neurons every two affected
that serve as hours parts has
the poorer
communicatio circulation
n system of
the body. They Plan care to to promote
carry carefully rest periods
messages in balance rest
the form of periods
electrical
impulses. The
messages COLLABORATI To probably
move from one VE: decrease
neuron to Administer cardiac
another to medications workload and
keep the body as ordered in
functioning. such as maximizing
Because antihypertensi tissue
neurons have, ve or perfusion
limited ability diuretics.
to repair
themselves
unlike other
body tissues
that is why
nerve cells
cannot be
repaired if
damaged due
to injury or
disease.