NURSING CARE PLAN

Cues Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective: Impaired physical Short term: Evaluate client’s perceived To provide comparative After 8 hours
“Galuya gid na mobility related to After 8 hours limitations by asking past baseline data and to provide of nursing
siya, halin body weakness of nursing activities and present activities. information about needed interventions,
paghuspital niya” secondary to CVA interventions, intervention. the client was
as stated by the the patient will Assess cardiopulmonary able to improve
SO be able to response to physical activity, Manifestation results and increase
increase including vital signs before, intolerance of activity. strength and
Objective: strength in during and after activity. function of
- Body weakness performing To provide an increase in affected body
noted ADL’s Provide and monitor response to oxygen supply. parts activities
-GCS 12 supplemental oxygen. To protect the client from as evidence of
(E4V4M4) Assist client with activities injury. increase GCS
Long term: when walking to the wash room, To minimize occurrence of from 12-15
After 3 days of getting up and lying fatigue.
nursing Provide intervals of rest
interventions, between activities. Helps to minimize
the patient will frustration and rechannel
be able to Encourage and acknowledge the energy.
improve and difficulty of the situation of the
increase client. Sunlight is rich in vitamin
strength and D and will help the client to
function of Encouraged patient to expose increase vitality.
affected body himself in sun light around 7- 8 To maintain and enhance
parts am. muscle tone of client.

Execute passive or active

assistive ROM exercise to all
extremities

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 NURSING CARE PLAN

Cues Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective: Impaired verbal After 8 hours of - Keep voice in a low - A high-pitched/loud After 8 hours of
communication nursing intervention manner and speak tone of voice can elevate nursing intervention
related to altered the client will have slowly as much as anxiety levels while the client expressed
Objective: perception as express thoughts and possible. slow speaking aids thoughts and feelings
- Memory loss evidenced by feelings in a understanding in a coherent,
- Brain damage difficulty of coherent, logical, - Keep environment - keep anxiety from logical, goal-directed
- Irritability communicating goal-directed manner calm, quiet and as escalating and manner as evidenced
-GCS 12 (E4V4M4) thoughts verbally free of stimuli as increasing confusion and by talking to his
secondary to CVD possible. hallucinations/delusions. family about his
bleed - Use clear or simple - Client might have concerns.
words, and keep difficulty processing
directions simple as even simple sentences.
well.
- When you do not - Pretending to
understand a client, understand limits your
let him/her know you credibility in the eyes of
are having difficulty your client and lessens
understanding. the potential for trust
- Use therapeutic - Even if the words are
techniques hard to understand,
(clarifying feelings try getting to the
when speech and feelings behind them.
thoughts are
disorganized) to try
to understand client’s
concerns.

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 Cues Nursing Diagnosis Planning Implementation Rationale Evaluation
Subjective: Altered of daily After 8 hours of - Assess abilities and level of - Aids in planning for After 8 hours of
living related to nursing deficit (0–4 scale) for meeting individual needs. nursing
discomfort as interventions, performing ADLs. interventions,
Objective: evidenced by patient will be able - Avoid doing things for patient - To maintain self-esteem patient was able to
-pain scale of 5/10 headache with pain to perform self-care that patient can do for self, but and promote recovery, it is perform self-care
-Headache scale of 5/10 activities within provide assistance as necessary. important for the patient to activities within
-Dizziness level of own ability do as much as possible for level of own
-Nausea self. ability
- Be aware of impulsive actions - May indicate need for
suggestive of impaired additional interventions
judgment. and supervision to promote
patient safety.
- Maintain a supportive, firm - Patients need empathy
attitude. Allow patient sufficient and to know caregivers
time to accomplish tasks. Don’t will be consistent in their
rush the patient. assistance.
- Provide positive feedback for - Enhances sense of self-
efforts and accomplishments. worth, promotes
independence, and
encourages patient to
continue endeavors.
- Encourage SO to allow patient - Reestablishes sense of
to do as much as possible for independence and fosters
self. self-worth and enhances
rehabilitation process

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 Cues Nursing Diagnosis Planning Implementation Rationale Evaluation
Subjective: Deficient knowledge After 8 hours of -Assess type and degree of - This will affect the After 8 hours of
“wala ko kis-a ga inum related to lack of nursing sensory perceptual involvement. choice of teaching nursing
bulong kay daw okay compliance to interventions, the methods and content interventions, the
man ko” as stated by medications as patient will be able complexity of client was able to
the patient. evidenced by verbalize instruction. verbalize
inaccurate follow- understanding of - Include SO and/or family in - These individuals will understanding of
Objective: through of instructions therapeutic regimen discussions and teaching. be providing therapeutic
- Uncooperative and rationale for support/care and have regimen and
- Irritability actions. great impact on rationale for
-He never use to patient’s quality of life. actions.
interact people with - Identify signs and symptoms - Prompt evaluation
high position. He has requiring further follow-up: and intervention
low self-esteem facing changes or decline in visual, reduces risk of
new faces. motor, sensory functions; complications and
-unable to understand alteration in mentation or further loss of function.
the questions easily. behavioral responses; severe - Recommended
Need to repeat the headache. activities, limitations,
question and emphasize - Reinforce current therapeutic and medication and/or
for him to understand. regimen, including use of therapy needs are
medications to control established on the basis
hypertension of a coordinated
interdisciplinary
approach.
- Provide written instructions - Provides visual
and schedules for activity, reinforcement and
medication, important facts reference source after
discharge.
- Encourage patient to refer to - Provides aids to
written communications or support memory and
notes instead of depending on promotes improvement
memory in cognitive skills.
- Suggest patient reduce - Multiple stimuli may
environmental stimuli, aggravate confusion,
especially during cognitive overwhelm the patient,
activities. and impair mental
abilities.

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 Cues Nursing Diagnosis Planning Implementation Rationale Evaluation
Subjective: Ineffective cerebral After 8 hours of - Assess factors related to - Assessment will After 8 hours of
tissue perfusion nursing intervention, individual situation for determine and influence nursing intervention,
related to hemorrhage patient will maintain decreased cerebral the choice of patient was able to
as evidenced by altered usual/improved level perfusion and potential for interventions. maintain
Objective: level of consciousness of consciousness, increased ICP. - Assesses trends in level usual/improved level
-Memory loss cognition, and - Closely assess and of consciousness (LOC) of consciousness,
-Headache motor/sensory monitor neurological and potential for cognition, and
-Pain scale of 5/10 function. status frequently and increased ICP and is motor/sensory
-dizziness compare with baseline. useful in determining function.
-nausea location, extent, and
-GCS 12 progression of damage.
-PSat 89% - Assess higher functions, - Changes in cognition
including speech, if patient and speech content are an
is alert. indicator of location and
degree of cerebral
involvement and may
indicate deterioration or
increased ICP.
- Position with head - Reduces arterial
slightly elevated and in pressure by promoting
neutral position. venous drainage and may
improve cerebral
perfusion.
- Administer supplemental - Reduces hypoxemia.
oxygen as indicated. Hypoxemia can cause
cerebral vasodilation and

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 increase pressure or
edema formation.

Cues Nursing Diagnosis Planning Implementation Rationale Evaluation

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Subjective: Risk for ascending After 8 hours of -monitor v/s -increase in temp
infection related to nursing specially the temp. indication of After 8 hours of
presence of foley interventions, -use aseptic infection nursing
O: Temp- 36.3 catheter. patient will be free technique during -prevent from interventions,
-presence of from any signs and cleaning the infection patient did not
catheter symptoms of catheter -faster recovery and manifested signs
-Undrain urine in infection -maintain healing and symptoms of
the urine bag. cleanliness in -prevent from infection
-4days of patient’s microorganism
catheterization environment contamination
-keep patient’s bed -fasten the healing
clean and dry and recovery
-encourage increase -away from any
oral fluid intake if complications
not contraindicated -to hasten wound
-tell patient to healing
comply to antibiotic -to prevent the
therapy as occurrence of
prophylaxis infection
-monitor -to determine
medication regimen effectiveness of
therapy

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