IX.

LIST OF PRIORITY PROBLEM

• Impaired Physical Mobility related to weakness and right hemiplegia

• Impaired Verbal Communication related to loss of facial muscle tone/control

• Self-Care Deficit related to loss of muscle control or coordination

• Risk for Aspiration related to regurgitation of food, fluid, or secretions

• Risk for Injury related to impaired mobility

 X. NURSING CARE PLAN

Nursing Nursing
Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation
Subjective: Impaired Due to brain Long Term Goal: Independent: Long Term
“Hindi niya physical mobility damage caused After 3 weeks of  Change position  Affected side has Goal:
maigalaw yung related to by stroke its nursing at least every 2 poorer circulation After 3 weeks of
kanang bahagi ng weakness and resulting effect is interventions, the hour. and reduces nursing
katawan niya at right hemiplegia the limitation in patient will be able sensation and is moreinterventions,
talagang independent to increase the predisposed to skin the patient was
nanghihina siya,” purposeful strength of the breakdown. able to increase
as verbalized by physical affected body part.  Begin  Minimizes muscle the strength of
the client’s wife. movement of the active/passive atrophy, promotes the affected
body or of one or ROM to all circulation, helps body part.
more extremities. extremities, prevent contractures.
encourage GOAL MET
Objective: exercise such as
- weakness squeezing rubber
- decrease muscle ball, extension of
strength/control fingers and legs.
- limited ability to  Encourage patient
perform gross to assist with  May respond as if
fine/motor skills movements and affected side is no
exercises using longer part of body
unaffected and needs
extremity to encouragement and
support/move active training.
weaker side.

Collaborative:
 Consult with
physical therapist
regarding active,  Individualized
resistive exercises program can be
and patient developed to meet
ambulation. particular needs/deal
with deficits in
balance, coordination
and strength.
 Nursing Nursing
Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation
Subjective: Impaired Impaired Long Term Independent: Long Term
“Kinausap ko verbal verbal Goal: Provide alternative methods of  To provide for Goal:
siya at bulol- communi- communica-  After 3 communication like visual clues communication of  After 3
bulol na ang cation tion is the months of (gestures, pictures, “needs” list, needs/desires months of
kanyang related to decreased, nursing demonstration). based on nursing
pagsasalita,” loss of delayed or interventions individual interventions,
as verbalized facial absent , the client situation/under- the client was
by the muscle ability to will be able Talk directly to patient, lying defects. able to
patient’s wife. tone/ receive, to establish speaking slowly and distinctly;  Reduce establish
control process, method of use yes/no questions to begin confusion/anxiety method of
transmits communicati with, progressing in complexity at having to communica-
and/or uses on in which as patient responds. process and tion in which
a system of his needs can respond to large needs are
symbols. be expressed. amount of expressed.
Objective: Speak in normal tones and information at
- stammering avoid talking too fast; give one time. GOAL MET
/stuttering patient ample time to respond,  Patient is not
of speech talk without response. necessarily
- facial hearing impaired,
paralysis and rising voice
- muscle and may irritate or
facial anger patient;
tension forcing responses
- inability to can result in
modulate frustration and
speech may cause patient
to resort to
“automatic”
Individualize techniques using speech, e.g.,
breathing for relaxation of the garbled speech,
vocal cords, note tasks, and obscenities.
singing or melodic intonation.  Individuals with
expressive
aphasia may talk
Encourage SO/visitors to persist more easily when
in efforts to communicate with they are relaxed
patient, e.g., reading mail, and when they are
discussing family happenings talking to one
even if patient is unable to person at a time.
respond appropriately.  It is important for
family members
to continue
 Nursing Nursing
Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation
Subjective: Self-care Motor deficit are Short Term Goal: Independent: Short Term Goal:
“Kinakailang deficit related the most obvious After 4 hrs of  Avoid doing  These patients After 4 hrs of
an ng asawa to loss of effect of stroke. nursing things for patient may become nursing
ko ang muscle Symptoms are interventions, the that patient can fearful and interventions the
suporta sa control or caused by patient will be able do for self, but dependent and patient was able to
paggawa ng coordination destruction of to identify provide although identify personal
kahit mga motor neurons in personal assistance as assistance is resources that can
simpleng the pyramidal resources that can necessary. helpful in provide assistance
bagay tulad pathways (nerve provide assistance preventing and was able to
ng pagkain at fibers in the and be able to frustration, it is verbalize
pag inom," as brain verbalize important for knowledge of
verbalized and passing knowledge of patient to do as health care
by the client's through the health care much as possible practices.
wife spinal practices. for self to
cord to the motor maintain self- Long Term Goal:
tract.) One of Long Term Goal: esteem and After 3 days of
Objective: those symptoms After 3 days of promote nursing
-with soiled could be nursing recovery. interventions, the
clothes inability interventions, the  Maintain  Patients need patient was able to
-with to perform patient will be able supportive, firm empathy and to demonstrate
unsatisfying ADLS. to demonstrate attitude. Allow know caregivers techniques/
appearance techniques/ patient sufficient will be lifestyle changes
-with minimal lifestyle changes time to consistent in to meet self-care
sweating to meet self-care accomplish their assistance. needs
-uncombed needs tasks.
hair  Provide positive  Enhances sense GOAL MET
feedback for of self-worth,
efforts and promotes
accomplishments independent, and
encourages
patient to
continue and
endeavors.
 Passive ROM to  Promotes
all limbs and circulation,
progress to muscle tone,
assistive and joint flexibility,
then active prevents
ROM in all contractures and
joints four times weakness.
a day.
 Nursing Nursing
Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation
Subjective: Risk for When there is Short Term Independent: Short Term
aspiration a blockage of Goal:  Provide soft  To aid swallowing Goal:
related to vertebrobasilar After 3 hours of foods that stick effort After 3 hours of
regurgitation artery nursing together/form a nursing
of food, fluid, there will be interventions, bolus. interventions,
or secretions cranial the patient will  Strict aspiration  To enhance the patient was
nerves be able to precaution and swallowing able
affectations. demonstrate small feeding demonstrate
CN techniques to  Moderate to  Use gravity to techniques to
V, VII, IX, prevent high back rest facilitate prevent
Objective: XII blockage aspiration. when feeding swallowing. aspiration.
> choke like may result to
symptoms dysphagia
during eating or difficulty of Long Term Long Term
swallowing Goal: Goal:
which After 2 days of After 2 days of
thereby having nursing nursing
high risk intervention the intervention the
for aspiration. patient will be patient was able
able to to experience no
experience no aspiration,
aspiration, noiseless
noiseless respiration, and
respiration, and clear breath
clear breath sounds.
sounds.
GOAL MET
 Nursing Nursing
Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation
Subjective: Risk for injury Because of Short Term Independent: Short Term
related to limited range Goal: Goal:
impaired of motion and After 3 months  Frequent skin After 3 months
 To assess if
mobility slightly of inspection of nursing
NCP FOR paralyze body, nursing there is presence interventions, the
HOME the patient is interventions, the of pressure ulcers patient was able
unable to patient  Use effective  To promote safety to demonstrate
mobilize will demonstrate lighting. and easy scanning behaviors,
properly which behaviors and lifestyle changes
of the environment
maybe a risk lifestyle changes to reduce risk
Objective: for injury. to reduce risk  To prevent injury factors and
 Remind client
factors and to walk due to slipping, protect self from
>fatigue protect self from slowly. and to promote injury .
>dizziness injury. safety
>weakness Long Term
>right Long Term  To prevent injury Goal:
 Keep things at
hemiplegia Goal: and promote After 6 months
home into
>no side rails After 6 months right premises safety of nursing
of nursing and clear the interventions, the
interventions, the way going to patient was able
patient will be the restroom to be free of
free of injury. injury.

GOAL MET