NURSING CARE PLANS ASSESSMENT S>Mula noong ma-Stroke siya hindi na siya makakilos at lagi na lang nakahiga.

Lahat ng bagay, kailangan na niya ng katulong gaya ng pagpupunas at pagbibihis, her husband said. O> Right Upper and Right Lower Extremities have muscle strength of 2/5 (can be moved passively, sometimes can hold against gravity but only for 1-2 seconds). Left Upper and Left Lower Extremities have muscle strength of only 1/5 (slight vibrations or contractions can only be felt). She DIAGNOSIS Impaired Physical Mobility r/t Neuromuscular Impairment: CVA as manifested by Decreased Muscle Strength on All Extremities PLANNING INTERVENTION After 6 hours of Assess general nursing condition of the intervention, the client client will not show further complications of immobility. Assess the patients ability to perform ADLs and ability to perform ROM. RATIONALE To determine any decrease in function with his body To identify causative/contributing factors Restricted movement affects the ability to perform ADLs. Assessing this provides baseline for future evaluation. Regular examination allows prevention and early recognition of pressure sores. EVALUATION After 6 hours of nursing intervention, the client did not show further complications of immobility.

Assess for the skin integrity. Note for redness especially in the bony prominences.

Assess elimination Immobility promotes pattern. constipation Initiate a fall prevention protocol; keep side rails up and bed in low position. Safety is a priority and raising the rails promotes safe environment

has inability to raise the Left extremities. Left hand could not grasp anything. Left foot could not be extended nor dorsiflexed. Left extremities has a very diminished active range of motion. She is not ambulatory.

Maintain limbs in functional alignment with the support of pillows

To maintain position of function and reduce risk of pressure ulcer. Maintaining proper alignment of extremities prevents contractures and other injuries. Exercise promotes increased venous return, prevents stiffness and maintains muscle strength and endurance.

Perform active and passive ROM exercises

Encourage Promotes well being adequate intake of and maximizes fluids/ nutritious energy production food Encourage enough bed rest Monitor vital signs Antispasmodic medications or muscle relaxants may reduce muscle spasms Conserve energy

Administer medication, as

prescribed To develop individual exercise/mobility program and identify appropriate mobility devices For adequate nutrition intake of the client

Consult with a physical/ occupational therapist, as indicated Consult with the nutritionist/dietitian about the intake of fluid and food of the client

ASSESSMENT S>Dahil nga hindi siya nakakatayo at nakakagalaw, nagkaroon siya ng bed sore sa likod. Naging mabasa basa ito. Sa ngayon mejo tumutuyo na, as verbalized by her husband. O> The patients skin is cold to touch and is dry. Skin on all extremities is slightly pale. Skin turgor is normal, no tenting formed upon pinching. She has a pressure ulcer at the sacral area about 1.5 inch in diameter, pinkish and dry in appearance.

DIAGNOSIS Impaired Skin Integrity r/t Prolonged Immobility as manifested by pressure ulcer on the sacral area

PLANNING After 6 hours of nursing interventions, the client will not manifest further complications of impaired skin integrity, rather experience pressure ulcer management.

INTERVENTION Assess the general condition of the patient and her skin in relation to age

RATIONALE Skin of older patients are less elastic, has less padding, less moisture, making it easier to be impaired. For baseline data

Assess the skin These areas are on the bony at higher risk of prominences (i.e. skin break down sacrum) due to ischemia from compression to hard surfaces. Assess clients Immobility is a risk ability to move factor in developing impaired skin integrity Assess the condition of the client in relation to systemic diseases such as DM and HTN. Patients w/ chronic diseases manifest multiple risk factors which lead to pressure ulceration future

EVALUATION After 6 hours of nursing interventions, the client did not manifest further complications of impaired skin integrity, rather experience pressure ulcer management through would care and proper positioning and turning.

Assess the Basis for characteristic and evaluation

stage of existing pressure ulcers Coordinate with health care team regarding turning and positioning schedule Turn and Position the client properly as ordered / advised. Promotes good skin integrity by reducing the pressure and restoring the blood flow

Change Diapers Wastes especially ASAP when it is Urine becomes already soiled harmful to the skin (due to Ammonia) Perform wound Reduce chances care to the of infection, and pressure sore promotes healing accompanied by aseptic technique Encourage adequate intake of fluids/ nutritious food Monitor Vital Promotes well being and healing and maximizes energy production These are altered

Signs (Temperature) Consult with a physical/ occupational therapist, as indicated

whenever there is infection

To develop individual exercise/mobility program and identify appropriate Consult with the mobility devices nutritionist/dietitian about the intake of For adequate fluid and food of nutrition intake of the client the client

ASSESSMENT S> Ngayon, naka-NGT na siya kaya wala akong problema sa pagkain niya. Baka nga lang mabulunan; sinasuction muna siya bago kumain eh, as verbalized by her husband.

DIAGNOSIS Risk for Aspiration r/t Presence of NGT for feeding

PLANNING After 30 minutes of nursing intervention, the client will not manifest signs of aspiration even before, during and after feeding.

INTERVENTION Assess Level of consciousness and Presence of Gag reflex Always position the client properly in a fowlers position.

RATIONALE These 2 are the most common risk factors of aspiration

EVALUATION After 30 minutes of nursing intervention, the client did not manifest signs of aspiration even before, during and after feeding.

Suction machine To provide should be ready at patent airway the bedside of the client. Suction as needed. Feed the client through the NGT with Strict aspiration precautions. 1. Auscultate the abdomen to check for the NGT placement 2. Assess for the residue in the NGT

To ensure that the NGT is placed in the stomach and not directed to the lungs. Prevents aspiration and aspiration pneumonia

Maintain the Law of Gravity; position of the client To avoid after feeding regurgitation of the stomach

contents, therefore to avoid aspiration also Monitor Vital Signs Altered VS determines any decrease in function

DRUG ANALYSIS NAME OF THE DRUG Aldactone / Spironolactone MODE OF ACTION Competitively blocks the effects of aldosterone in the renal tubule causing loss of sodium and water and retention of potassium INDICATION Indicated for Hypertension in combination with other drugs CONTRAINDICATIONS -Allergy to Spironolactone -Hyperkalemia -Pregnancy and Lactation SIDE EFFECTS -Dizziness -Headache -Abdominal Cramping -GI Distress ADVERSE EFFECTS -Hyperkalemia -Hyponatremia PHARMACOKINETICS Route is Oral Onset is 24-48 hours Peak occurs at 48-72 hours Duration is 48-72 hours NURSING RESPONSIBILITIES -Assess allergy to medication prior to administration. -Administer in accordance to doctors order. -If contraindicated, do not administer The drug is -Inform side effects metabolized and encourage hepatically with client to inform T1/2 = 20 hours. health care provider It is excreted regarding untoward through the feces. reactions -Avoid potassiumrich foods -Assess Kidney Function

DRUG CLASS Potassium Sparing Diuretic

NAME OF THE DRUG Telmisartan

DRUG CLASS Angiotensin II receptor Antagonist; Antihypertensive

MODE OF ACTION It blocks the binding of angiotensin II to specific tissue .receptors found in the vascular smooth muscles and adrenal gland; this action blocks the vasoconstriction effect of the rennin angiotensin system as well as the release of aldosterone leading to decreased BP.

INDICATION It is indicated for hypertension; because an increased BP may lead to rupture of blood vessels or may lead to dislodging thrombus (becoming an embolus), wherein it could lead to another episode of CVA, hence she has HTN. CONTRAINDICATIONS -Allergy -Hepatic and Nephro impairment -Pregnancy

SIDE EFFECTS Headache, Dizziness, Mild GI Distress

PHARMACOKINETICS Route is Oral. Onset varies. Peak occurs between 0.5 1 hour It is metabolized hepatically with T1/2 of 24 hours It could be distributed through the placenta and breast milk

NURSING RESPONSIBILITIES -Assess allergy to medication prior to administration. -Administer in accordance to doctors order. -If contraindicated, do not administer -Inform side effects and encourage client to inform health care provider regarding untoward reactions -Always assess for symptoms of hypotension.

ADVERSE EFFECTS Hypotension

Excreted through feces

NAME OF THE DRUG Metoprolol

DRUG CLASS Antihypertensive; Beta 1 Adrenergic blocker

MODE OF ACTION Blocks beta adrenergic receptors of sympathetic nervous system in heat and juxtaglomerular apparatus (kidney) thus decrease the excitability of the heart, decrease cardiac output and oxygen consumption, decrease the release of renin from the kidney and lowering BP.

INDICATION It is indicated for hypertension; because an increased BP may lead to rupture of blood vessels or may lead to dislodging thrombus (becoming an embolus), wherein it could lead to another episode of CVA, hence she has HTN. CONTRAINDICATIONS -Allergy -Sinus bradychardia, second-or-thirddegree heart block, cardio genic shock, hear failure

SIDE EFFECTS -GI Distress -GU disturbances: impotence, decreased libido

PHARMACOKINETICS Route is oral. Onset is 15 minutes; Peak is 90 minutes. The duration varies. It is metabolized hepatically with T1/2 of 3-4 hours. It is excreted through the urine.

NURSING RESPONSIBILITIES -Assess allergy to medication prior to administration. -Administer in accordance to doctors order. -If contraindicated, do not administer -Inform side effects and encourage client to inform health care provider regarding untoward reactions -taper drug gradually after 2 weeks with monitoring, if discontinuing the drug -consult with the physician about withdrawing

ADVERSE EFFECTS -Hypotension -Heart Failure

NAME OF THE DRUG Kalium Durule

DRUG CLASS Potassium Chloride

MODE OF ACTION Replaces potassium, thus maintaining potassium levels

INDICATION Hypokalemia; Prophylaxis to diuretic treatment CONTRAINDICATIONS -oliguria -anuria -untreated Addisons disease -cardiac disease and renal impairment

SIDE EFFECTS GI Distress

PHARMACOKINETICS Onset is slow and Duration is 1-2 hours. It is metabolized in the cellular level and is excreted in the urine

ADVERSE EFFECTS -Arrhythmia -Heart block -Hyperkalemia

NURSING RESPONSIBILITIES -Assess allergy to medication prior to administration. -Administer in accordance to doctors order. -If contraindicated, do not administer -Inform side effects and encourage client to inform health care provider regarding untoward reactions -Provide feedings if GI disturbances occur.