Nursing Care Plan

Cues Nursing Analysis Goal and Objectives Interventions Rationale Evaluation

Diagnosis

Subjective: Activity A stroke is the Goal:

The client Intolerance rapidly developing After 8 hours of proper Goal was met.
verbalized: related to loss of brain nursing interventions,
-“Nahihirapan decrease function(s) the client will be able to
talaga ako blood flow due to enhance activity
maglakad lalo na a disturbance in tolerance.
dito sa kaliwang the blood supply to
paa ko” the brain.
-“mga 5 out of 10 This can be due Objectives:
parin yung sakit to ischemia (lack of After 30 minutes of
na ramdam ko blood supply) nursing intervention
pag naglalakad caused and health teachings:
ako” by thrombosis or e Developmental:
mbolism or due to
a hemorrhage. -The client will -Explain to the client Range of motion The client was
Objective: understand the the importance and exercises help keep able to
-In the nursing As a result, the importance of ROM good effect of ROM your joints and understand the
chart, the client is affected area of the exercises. exercises. muscles as healthy as importance of
diagnosed to brain is unable to possible. Without the ROM
have function, leading these exercises, blood exercises.
Intracerebral to inability to move flow and flexibility
Hemorrhage at one or more limbs (moving and bending)
the ® upper on one side of the of your joints can
medial frontal body, inability decrease. Joints, such
lobe to understand or as your knees and
-there is (+) formulate speech elbows, could become
difficulty in or inability to see stiff and locked
ambulation one side of the without range of
-during the visual field motion exercises.
interview there is (http://www.family-friendly-
slight slurring of fun.com/therapy/passive-
In the past, stroke range-motion.htm)
speech. was referred to as
cerebrovascular
Measurement: accident or CVA, To enhance
BP: 150/90 but the term -The client will be able -Teach and The client was
RR: 26 "stroke" is now to learn at least 3 out of demonstrate 5 able to learn 3
PR: 80 preferred. 5 ROM exercises. appropriate ROM knowledge. out of 5 ROM
exercises. exercises.
(reference: To prevent or limit
http://en.wikipedia.org/ deterioration.
wiki/Stroke)
(NANDA, page64 )

-The client will be able -Instruct client to The client was

to demonstrate and demonstrate To be able to evaluate able to
participate in the ROM appropriate ROM the acquired demonstrate
exercises. exercises to the knowledge and skills ad participate
client. on the given in the
situational scenario. exercises.

Supplemental:
-To avoid injury.
-Client’s safety will be - Take safety (NANDA, page64) The client’s
ensured. precautions To prevent safety was
occurrence of ensured.
accidents and other
complications.
(www.scribd.com/doc/2432
886/Cardiovascular-
Exercise-Safety-
Precaution)

-Client’s response will -Monitor the patient The client’s

be monitored. regularly for any To prevent response was
signs of distress overexertion. monitored.
during the exercise. (NANDA, page63)

-Client’s vital signs will -Monitor and The client’s

be monitored. document vital signs. Vital signs are vital signs was
measures of various taken and
physiological statistics recorded.
often taken by health
professionals in order
to assess the most
basic body functions.
Also to establish
 baseline data.
(http://en.wikipedia.org/wiki
/Vital_signs)
Collaborative:

-Due medications will -Check physician’s Due

be given. order then administer To prevent any errors. medications
drugs. Only privileged were given.
physicians and
residents under their
supervision can order
medications.
(http://hcpc.uth.tmc.edu/pro
cedures/volume2/chapter3/
treatment_services-32.htm)

-Any side effects of the -Monitor any possible (If any) side
drugs to the client will abnormal signs and To prevent further effects was
be monitored. symptoms. complications monitored.
(NANDA)