St.
Anthony’s College
San Jose, Antique
Nursing Department
NAME: P. G
AGE: 77
Dr.: Quilantang
CC: Right sided weakness NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OJECTIVE: Impaired physical Limitation in Long-term INDEPENDENT: After 2 days
mobility of the upper independent, purposef of nursing
OJECTIVE: and lower ul physical movement After 2 days of nursing Assess degree To initiate proper care interventions, the
Right sided extremities r/t of the body or of one interventions ,the patient will be of immobility produced and be able to assist in patient was able to:
weakness neuromuscular or more extremities able to: by injury/treatment. some part of the
skeletal impairment patient’s ADLs 1.) Goal
Limited ROM As evidence by 1.) Demonstrate techniques Encourage use partially
limitation in moving, or behaviors that enable of isometric exercises Isometrics contract met.
Assisted with decrease muscle resumption of activities starting with the muscles without demonstrated
hourly turning to strength, and unaffected limb. bending joints or partially in meeting
different positions assisted when moving limbs and help basic needs by
turning and moving maintain muscle cooperating with
Slowed strength and mass. the student nurses
movements as well to other
Improves muscle healthcare team by
Gait changes 2.) Participate in ADLs and Assist with/encourage strength and doing ADL’s
desired activities self-care activities (e.g., circulation, enhances
Postural Instability bathing, shaving). patient control in 2.) Goal
during situation, and promotes partially
performance of self-directed wellness. met.
routine ADL’s participated in the
activities conducted
Tremors by the student
nurses such as
Prevents/reduces frequent turning
incidence of skin and every 2 hours,
Reposition periodically respiratory allowing to have an
every 2hours and complications (e.g., oral care,
encourage coughing/deep- decubitus, atelectasis, responding by
3.) Maintain position breathing exercises. pneumonia) nodding in closed
of function and skin ended questions
integrity as evidenced Bed rest, use since patient have
by absence of analgesics, and difficulty in
of contractures, Auscultate bowel sounds. changes in dietary uttering words.
footdrop, decubitus, and Monitor elimination habits habits can slow
so forth. and provide for peristalsis and produce
regular bowel routine. constipation. Nursing 3). Goal partially
Place on bedside measures that facilitate met.
commode, if feasible, or elimination Maintained position
use fracture pan. Provide may prevent/limit and function of skin
privacy complications. Fracture integrity by not
pan limits flexion of manifesting any
hips and lessens early signs of skin
pressure on lumbar impairment.
region/lower extremity
cast.
COLLABORATIVE: Creates positive
Work hand in hand with assurance in
other allied healthcare maintaining the quality
team in of care and update the
maintaining patient’s current status of
treatment and the patient.
functionality
St. Anthony’s College
San Jose, Antique
Nursing Department
NAME: P. G
AGE: 77
Dr.: Quilantang
CC: Right sided weakness NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OJECTIVE: Self Care deficit Motor deficit are the Short-Term INDEPENDENT:
related to most obvious effect .
Inability to feed musculosleletal of stroke. Symptoms After 8 hrs. of nursing 1. Establish rapport To promote After 8 hrs.
self independently impairement are caused by intervention patient will be able with the patient cooperation Of nursing
secondary to CVA destruction of motor to identify personal resources intervention
Inability to dress neurons in the that can provide assistance and 2. Monitor vital signs To have patient did
self independently pyramidal pathways be able to verbalize knowledge baseline data not identify
(nerve fibers in the of health care practices personal
Inability to bathe brain and passing 3. Assess for type Provides data resources
and groom self through the spinal and severity of regarding that can
independently cord to the motor immobility mobility and provide
tract.) One of those impairment , ability to assistance
Inability to symptoms could be muscle flaccidity, perform and be able
ambulate inability to perform spasticity and activities in to verbalize
independently ADLS. coordination, limitations knowledge
ability to walk, sit, without injury of health
With minimal move in bed or frustrations care
sweating practices
4. Passive ROM to Promotes
all limb and circulation,
progress to muscle tone,
assistive and then joint flexibility,
prevents
Long-Term active ROM in all contractures After 2 days
joints four times a day and weakness of nursing
After 2 days of nursing intervention
intervention patient will 5. Use assistive Provide safe patient did
demonstrate techniques/lifestyle devices as support for not
changes to meet self-care needs. appropriate for immobility and demonstrate
ambulation, assist other self care techniques/l
patient on personal activities to ifestyle
hygiene such as promote changes to
brushing teeth and independence meet self-
combing hair. Use care needs
clothing that is
easily managed to
dress and undress GOAL NOT MET
St. Anthony’s College
San Jose, Antique
Nursing Department
NAME: P. G
AGE: 77
Dr.: Quilantang
CC: Right sided weakness NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OJECTIVE: Ineffective cerebral The presence of partial Short-Term INDEPENDENT:
tissue perfusion blockage of the blood .
Altered LOC; related to interruption vessel can be multi After 8 hrs. Of nursing 1. Monitor and Assesses trends After 8 hrs. Of
memory loss of blood flow factorial. These can be intervention the patient will be document in LOC and nursing intervention
due to able to display decrease signs of neurological status potential for the patient was able
Restlessness vasoconstriction, ineffective tissue perfusion as frequently and increased ICP to display decrease
platelet adherence on evidence by gradual compare with and is useful in signs of ineffective
Changes in motor rough surface, fat improvement of vitals sings baseline. determining tissue perfusion as
response; accumulation and Display no further deterioration location, evidence by gradual
therefore decreases or recurrence of deficits extent, and improvement of
extremity elasticity of vessel progression or vitals sings
weakness; wall leading to resolution of BP- `130/90
alteration of blood CNS damage. T-36.1
paralysis perfusion with the May also PR-92
initiation of the reveal TIA, RR-17
Speech clotting sequence. which may O2- 100%
abnormalities/slurr This may later lead to resolve with no
ing of speech the development further Display no further
of thrombus which can symptoms or deterioration or
Changes in vital be loosened and may precede recurrence of
signs dislodged in some thrombotic deficits
areas of the brain such CVA.
as midcerebral carotid
artery hat may lead to 2. Document changes
alteration of blood Long-Term: in vision, such as
perfusion and further After 2 days of nursing reports of blurred Specific visual After 2 days of
develop to cerebral intervention the patient will: vision and alterations nursing intervention
infarct. Maintain usual or improved alterations in reflect area of the patient was able
LOC, cognition and motor and visual field or brain involved, to
sensory function depth perception. indicate safety Maintain usual or
concerns, and improved LOC,
influence cognition and
3. Assess higher choice of motor and sensory
functions, interventions. function as
including speech if evidenced by
client is alert. Changes in responding through
cognition and nodding in some
speech content questions and
are an participating in
indicator of frequent turning.
location and
degree of
cerebral
involvement
and may
4. Position with head indicate
slightly elevated increased ICP
and in neutral
position Reduces atrial
pressure by
promoting
venous
drainage and
may improve
cerebral
circulation and
5. Maintain bedrest, perfusion
provide quiet
environment, and
restrict visitors or Continual
activities as stimulation can
indicated. Provide increase ICP.
rest periods Absolute rest
between care and quiet may
activities, limiting be needed to
duration of prevent
procedures recurrence of
bleeding in the
case of
DEPENDENT: hemorrhagic
stroke
1. Provide and
maintain oxygen
as ordered
Aids in
2. Perform GCS difficulty of
monitoring as breathing
ordered
To detect
changes
indicative of
worsening or
3. Administer improving
medications as condition
indicated
To promote
wellness to the
patient
