IX.

LIST OF PRIORITY PROBLEM

• Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to CVA
• Impaired verbal communication related to loss of facial or oral muscle tone control
• Impaired physical mobility related to neuromuscular involvement secondary to CVA infarct
• Risk for Aspiration related to regurgitation of food, fluid, or secretions
• Risk for Injury related to impaired mobility, decreased visual acuity, and physical environmental hazards
X. NURSING CARE PLAN

Nursing Nursing Interventions

Assessment Diagnosis Rationale Planning Rationale Evaluation
Subjective: Ineffective Ineffective Short Term Goal: Independent: Short Term Goal:
“Nanghihina cerebral tissue  After 4 hours  Check capillary refill  To determine  After 4 hours of
siya!” as tissue perfusion is of nursing and conjunctiva blood nursing
verbalized by perfusion the decrease intervention circulation interventions, the
the patient’s related to in oxygen patient will  Elevate head of the  To promote client was able to
wife. interruption resulting in demonstrate bed to 30 degrees as blood demonstrate
of blood the failure to signs of ordered circulation increased perfusion
flow nourish the ineffective  Advise patient to  Enough rest is as individually
Objective: secondary tissues at the tissue have a enough rest needed to appropriate.
- extremity to CVA capillary perfusion as conserve
weakness level. [Tissue evidence by energy Long Term Goal:
- restlessness perfusion gradual  Avoid neck flexion  To avoid  After 3 days of
>Capillary problems can improvement and extreme hip/knee obstruction of nursing
refill exist without of vital signs extension arterial and interventions, the
longer than 3 decreased venous blood client was able to
secs. cardiac Long Term Goal: flow demonstrate
output;  After 3 days  Provide and maintain  Aids in behaviors which
however, of nursing oxygen as ordered difficulty in may improve
there may be intervention breathing proper
a relationship the patient will  Perform GCS circulation such
 To detect
between be able to as compliance to
changes
cardiac gradually health
indicative of
output and improve tissue management &
worsening or
tissue perfusion as therapies
improving
perfusion.] evidence by Dependent: provided.
condition
good capillary  Administer
 to promote
refill and pink GOAL MET
medication as ordered wellness
conjunctiva.
 Nursing Nursing
Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation
Subjective: Impaired verbal Impaired verbal Short Term Independent Short Term
“Nakita naming communication communication Goal: Maintain a calm,  To identify Goal:
siyang related to loss is the decreased,  After 3 hours unhurried manner, any other  After 3 hours
nabubulol,” as of facial or oral delayed, or of nursing Provide sufficient time deviations of nursing
verbalized by muscle tone absent ability to interventions, the for client to respond. from normal. interventions,
the patient’s control receive, client will be able Individualize the client was
wife. process, to verbalize or techniques using  Individuals able to
transmits and/or indicate breathing for relaxation with verbalize or
uses a system of understanding of of the vocal cords, rote expressive indicate
symbols. the tasks, and singing or aphasia may understanding
communication melodic intonation talk more of the
difficulty and easily when communicatio
Objective: plans for ways of they are n difficulty
- Difficulty handling. relaxed and and plans for
producing Interdependent when they are ways of
speech Long Term  Note Results of talking to one handling.
- Facial Goal: Neurologic test person at a
paralysis  After 3 days of time. Long Term
- Muscle and nursing  Use and assist  To assist Goal:
facial tension interventions, the client/ SO’s to aphasic clients > After 3 days of
client will be able learn therapeutic in relearning nursing
to establish communication speech. interventions, the
method of skills of  Improves client was able to
communication in acknowledgement, general establish method
which needs can active-listening, communicatio of
be expressed. and I-messages. n skills, communication
in which needs
are expressed.

GOAL MET
 Nursing Nursing
Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation
Subjective: Impaired Due to brain Short Term Independent:  To assess Short Term
“Hindi siya physical damage caused Goal:  Note functional Goal:
makagalaw mobility by stroke its  After 4 hours emotional/ abilities After 4 hours of
nung related to resulting effect of nursing behavior nursing
pagkagising neuromuscular is the intervention, responses of intervention,
namin nung involvement limitation in patient will be problems to patient is was
umaga, kaya secondary to independent able to immobility able to
dinala na CVA infarct purposeful participate in participate in
namin siya physical activities  Determine the  To assess the activities
agad sa movement of necessary for readiness of expected level necessary for the
ospital” as the body or of the patient the patient to of patient
verbalized by one or more engaged to participation
the client’s extremities. activity
wife. Long Term Goal: Long Term
 After 3 days  Assist patient  To promote Goal:
of nursing reposition self optimal level After 3 days of
intervention on a regular of function nursing
Objective: the patient schedule and prevent intervention the
> weakness will be able to complication patient was able
> limited increase the and to prevent to increase the
motor skills strength of the occurrence of strength of the
> limited affected body injury affected body
ability to part part
perform gross  Provide safety  Limits
fine/motor measure fatigue,
skills including fall maximizing
prevention participation
GOAL MET
 Nursing Nursing
Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation
Subjective: Risk for When there is Short Term Independent: Short Term
Aspiration a Goal:  Note level of  As impairments in Goal:
related to blockage of After 3 hours of consciousness these areas After 3 hours of
regurgitation vertebrobasilar nursing awareness of increase the nursing
of food, fluid, artery intervention the surroundings, client’s risk of intervention the
or secretions there will be patient will be and cognitive aspiration patient was able
Cranial able to function demonstrate
nerves demonstrate techniques to
affectations. techniques to  Assess the  Helps to prevent
CN prevent aspiration client’s ability determine aspiration
Objective: V, VII, IX, to swallow presence/effective
> choke like XII blockage and strength ness of protective
symptoms may result to Long Term of gag/cough mechanism Long Term
during eating dysphagia Goal: reflex and Goal:
or difficulty of After 2 days of evaluate After 2 days of
swallowing nursing amount/ nursing
which intervention the consistency of intervention the
thereby having patient will able secretion patient was able
high risk to experience no experience no
for aspiration aspiration,  Provide soft  To aid swallowing aspiration,
noiseless foods that noiseless
respiration, and stick respiration, and
clear breathe together/form clear breathe
sounds a bolus sounds

GOAL MET
 Nursing Nursing
Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation
Subjective: Risk for Injury Because of Short Term Independent: >To note for the Short Term
related to limited range Goal:  Assess pt’s Goal:
etiology or
impaired of motion and After 3 months of general condition After 3 months
slightly nursing precipitating of nursing
mobility,
decreased paralyze body intervention the pt factors that can intervention the
the patient is will demonstrate lead to fever. patient was able
visual acuity,
unable to behaviors, to demonstrate
and physical mobilize lifestyle changes behaviors,
environmental >Assess mood, >that may result
properly which to reduce risk lifestyle changes
hazards coping abilities, in carelessness
Objective: maybe a risk factors and to reduce risk
for injury protect self from personality style and increased risk factors and
>Fatigue injury taking without protect self from
>headache considerations of injury
> grab bars Long Term Goal:
consequences
> Right arm After 6 months of Long Term
and leg are nursing Goal:
weaker than intervention, >Frequent skin > To assess if After 6 months
the left. patient will be free inspection there is presence of nursing
of injury of pressure intervention,
ulcers. patient was able
to be free of
injury
>Use effective >To promote
lighting safety and easy GOAL MET
scanning of the
environment.

>Remind client to >To prevent injury

walk slowly due to slipping,
and to promote
 safety.

>Keep things into

>To prevent
right premises
and clear the way injury
going to the and promote
restroom safety
 Nursing Nursing
Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation
Subjective: Disturbed Proper rest After 2 shifts, the Independent: - High percentage of Goal met:
sleeping and sleep are patient will sleep disturbances are
“Ang hirap pattern r/t as important achieve optimal -Assessed sleep affected by illnesses. After 2 shifts,
makatulog sa interruptions to good health amount of sleep pattern the patient
gabi, hindi rin for as good as evidenced by disturbances that achieve optimal
ako makatulog therapeutics, nutrition and rested are associated with amount of sleep
kahit sa umaga monitoring, specific - To determine usual as evidenced by
adequate appearance, sleep pattern and
kasi lagi other exercise. verbalization of underlying rested
akong illnesses. provide appropriate appearance,
generated Individuals feeling rested, intervention.
minomonitor,” awakening, need different and improvement verbalization of
as verbalized -Observed and feeling rested,
and excessive amounts of in sleep pattern. obtained feedback
by the patient. stimulation sleep and rest. and
from clients improvement in
Objective: (noise and Physical and regarding usual
lighting) emotional sleep pattern.
bedtime, routines, - To avoid
-Dark circles health depends # of hours of disturbances during
under eyes on the ability sleep, and sleep, and to
to fulfill the environmental maximize sleeping
-Restlessness
basic human needs. process.
-Irritability needs.
Without -Did as much care
-Yawning proper amount as possible
- So that patient will
of rest and without waking
- Slowed have an understanding
sleep, just like the client, and did
movements of the importance of
in my as much care as
care being done to
-Fatigue patient’s case, possible while the
him. Minimizes
the ability to patient is still
complaints.
concentrate, awake.
make -Explained - To enhance ability to
judgments, necessity of fall asleep.
and participate disturbances for
in daily monitoring VS
activities and care when
decreases and hospitalized.
irritability - To relieve
increases. -Encouraged discomfort and take
wearing eye cover, maximum effects of
drinking warm sedatives.
milk, and sleeping
at the same time
each night.

Dependent:

-Administered
pain meds.