NURSING CARE PROCESS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective cues: Impaired verbal A CVD, which may be After 3 days of >Monitored vital >Establishes The client has
“ Nahihirapan communication caused by, nursing signs with emphasis baseline data for established method of
siyang umimik”, as related to hemorrhage, interventions, the to BP. review of existing communication in
verbalized by the alteration of thrombus, embolism or client will conditions. (Nursing which needs can be
relative. motor speech vasospasm, can result establish method
th
Care Plan, 6 edition, expressed as
Gulanick/Myers pg.
area of the in a local area of cell of communication evidenced by :
565)
Objective cues: brain death, called infarct. It in which needs
> non – verbal is caused by a lack of can be >Provided an  “Salamat” as
>Impaired ability to
response when blood supply which is expressed. atmosphere of verbalized by
communicate
asked then surrounded by an acceptance and the client.
spontaneously is
area of cells that are privacy through  Established
frustrating and
> difficulty of secondarily affected. speaking slowly and eye contact
embarrassing.
forming words Since symptoms in a normal tone, not while
Nursing actions
noted depend on the location forcing the client to communicating
should focus on
of the stroke and size communicate. with others
decreasing the
> LOC - lethargy of the infarct, it could
tension and  Used paper
involve the brain’s and pen to
conveying an
> GCS= 10 Brocca’s area, which is express needs
 primary responsible for
>restlessness communication
noted through facial
expressions and
speech. By causing
damage to this area,
the patient’s
communicating skills
are greatly altered and
affected.
(Medical- Surgical Nursing,
vol.2,9th edition, Brunner &
Suddarths, page 1259 )
understanding of
how difficult the
situation must be
for the client.
(Nursing Care Plan, 6th
edition, Gulanick/Myers
pg. 565)
>Deliberate actions
>Taught techniques
can be taken to
to improve speech
improve speech. As
by initially asking
the client’s speech
questions that client
improves, his
can answer with a
confidence will
“yes” or “no”.
increase and she
will make more
attempts at
speaking. (Nursing
Care Plan, 6th edition,
Gulanick/Myers pg.
565)
>Used strategies to >Improving the
improve the client’s client’s
comprehension by comprehension can
using touch and help to decrease
behavior to frustration and
communicate increase trust.
calmness and Clients with aphasia
adding other non – can correctly
verbal methods of interpret tone of
communication such voice. (Nursing Care
as pointing or using Plan, 6th edition,
Gulanick/Myers pg.
flash cards for basic
566)
needs; using
pantomime; or using
paper and pen.

>Involved the
>Enhances
significant others in
participation and
the plan of care.
commitment to
plan. (Nursing Care
Plan, 6th edition,
 Gulanick/Myers pg.
566)

>Imparts thought
and answers the
>Educated relatives
needs of the client
to establish a
with lessened
method of
difficulty. (Nursing
communication
Care Plan, 6th edition,
through sign
Gulanick/Myers pg.
language. 566)