CONCEPT MAP

Predisposing Factor: Age Gender Genetics Precipitating Factor: Nutritional Status Activity / Stress Lifestyle

CVA, DM and HYPERTENSION

S/sx: Stiffening of extremities Upward rolling of eyeballs Drowsy Unresponsive Chest pain

Impaired physical mobility r/t neuromuscular damage involvement as evidenced by motor control

Imbalanced Nutrition; less than body requirements related to inadequate dietary intake, loss of appetite as evidenced by loss of weight.

Ineffective Airway Clearance related to secretions in the bronchi.

Risk for Infection related to disease condition.

Risk for prone behaviour related to lack of knowledge about the disease.

After 8 hrs. Of Nursing Intervention, client will be able to participate in therapeutic regimen Expected outcome: Verbalize understanding of the situation. Verbalization of understanding the therapy. Able to participate in the interventions rendered by the nurse.

After 4 hours of nursing intervention the client verbalize understanding of having adequate intake of nutritious food.

After 8-hours of Nursing Intervention the clients mucous secretions would be lessened.

Determine degree of immobility Observe movement when client is unaware. Support affected part with pillows Give rest periods to The client is able to activities participate adequate Encourage on the fluids and right diet therapeutic as necessary to the regimen as client. evidenced by verbalization of understanding of the situation, therapy, and he is able to participate in the interventions rendered by the nurse.

Ascertained understanding of individual nutritional need. Discussed eating habits food preferences, intolerance/aversio n. Noted age, body build, strength, activity rest level. Promoted pleasant, relaxing environment. Prevented/ minimized unpleasant odour sight. Assisted with oral care after meals. After 4 hours of use Instructed SO to flavouring agents, intervention the if salt is restricted. client was able to enumerate at least 2 ways on how to prevent malnutrition.

After 4 hours of Nursing Intervention the risks factors of occurrence of infection will be reduce or control to a manageable level by a clean bed and maintain skin intact.

After 8 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment regimen.

Encourage deepbreathing and coughing exercises. Give expectorant or bronchodilato rs as ordered. Instruct increase fluid intake. Encourage or provide warm versus cold liquids as appropriate. Elevate head of the bed or change After 8 hours, position in of Nursing (2) every two Intervention hours. the clients mucus secretions were lessened.

Define and state the limits of desired BP. Encourage client to look at/touch affected body part. Change dressing. -provide a safe and quiet After 4 hours environment of Nursing . Intervention the pt. shall Encourage have identified verbalizatio of risks factors n of and role occurrence of play infection shall anticipated have reduced conflicts. or controlled to a Encourage manageable to increase level by a fluid intake clean bed and skin intact. Explain Hypertension and its effect on the heart, blood vessels, kidney and Brain. Assist the patient in Identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. Reinforce the Importance of After 8 hours of adhering to nursing treatment regimen interventions, and keeping follow the patient was up able to verbalize appointments. understanding Suggest frequent of the disease position changes, process and treatment leg exercises when regimen.