Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired verbal After series of 1. Assess 1. Helps After series of

communication nursing type/ determine nursing
related to intervention the degree of area and intervention the
impaired cerebral client will be able dysfunction degree of brain client was able to
circulation as to participate in . involvement participate in
Objective: evidenced by the therapeutic and difficulty therapeutic
objectives. communication. patient has communication.
-difficulty with any or all
expressing -maintain good steps of the -maintain good
thoughts verbally environment communicatio environment
n process.
-difficulty -enhance -enhance
comprehending participation and participation and
communication communication communication
pattern plan plan
2. Good
-Paralysis on left communicatio
part of the body 2. Use simple
communica n involves
tion speaks many familiar
in a well- concepts,
modulated including sore
voice, eye contact.
smile, and
shown
concern for
the client.
3.Establish 3.To build trusting
rapport relationship

4. To have
baseline data.
4.Monitor and
records vital sign 5. To maintain
good
5. Establish good communication
relationship, skills with the
listening carefully patient.
and attending to
clients verbal and
non-verbal
expressions. 6. To give right
manner when
6. Provide communication.
sufficient time for
client respond.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Impaired physical After series of 1. Observe the 1. Some After series of
mobility related nursing client for cause of clients nursing
to neuromuscular intervention the impaired mobility. choose not intervention the
impairment client will be able to move client was able to
Objective: to verbalize because of verbalized feeling
feeling of physiologica of increased
-Slowed increased l factors strength and
movement strength and such as an ability to move
ability to move inability to
-difficulty of cope or
turning 2. Change depression.
positions at 2. Reduce risk
least every 2 of tissue
hours and ischemia /
possibly injury.
more often if Affected
placed on side has
affected side. poorer
circulation
and reduced
sensation
and is more
predisposed
to skin
breakdown /
decubitus.

3. Maintain leg 3. Prevents

in neutral external hip
position with rotation.
a trochanter
roll.
4. Inspect skin 4. Pressure
regularly, points over
particularly bony
over bony prominence
prominence. are most at
Gently risk for
massage any decreased
reddened perfusion.
areas and Circulatory
provide aids stimulation
such as and padding
sheepskin help pre
pads as vents skin
necessary. breakdown
decubitus.

5. Aids in
retraining
5. Assist to neuronal
develop pathways,
sitting enhancing
balance. propriocepti
on and
motor
response.

6. Promotes
sense of
6. Set goals expectation
with patient of progress,
significant improvemen
others for t and
participation provides
in activities some sense
exercise and of control,
 position independen
changes. ce

7. May
respond as
7. Encourage if affected
patient to side is no
assist with longer part
movement of body and
and exercises needs
using encouragem
unaffected ent and
extremity to active
Support, training to
move weaker “reincorpora
side. te” it as a
part of own
body.