NURSING CARE PROCESS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective cues: Impaired Deprivation of oxygen After 3 days of >Monitored vital >Establishes The client was able to
“ Mabigat at physical supply of the brain nursing signs. baseline data for maintain and increase
ngimay pa din ang mobility related tissue may result to interventions, the review of existing strength and function
pakiramdam ng to hypotonic nerve damage which client will be able conditions. (Nursing of affected and
kaliwang kamay at paralysis of left may affect the to improve and
th
Care Plan, 6 edition, compensatory body
paa ko”. Gulanick/Myers pg.
side of the individual’s increase strength part as evidenced by:
561)
body sensorimotor ability and function of
Objective cues: secondary to that may result to affected and  Increased
>This information is
decreased limitation of the compensatory >Monitored and ROM such as
used to determine
> patient is oxygenation of independent, body parts. recorded turning from
and prevent life –
bedridden the right side of purposeful movement neurological status side to side as
threatening
the brain. of the body or of one or using Glasgow observed.
complications such
>limited range of more extremities. Coma Scale.  Able to move
as severe
motion observed her hand as
hypertension and
response
increased ICP.
>uncoordinated (Medical- Surgical Nursing
(Nursing Care Plan, 6th  Able to flex
movements Critical Thinking for
edition, Gulanick/Myers extremities
observed collaborative care, vol.1,5th
pg. 561)
 edition, Ignatius, et.al, page with assistance
2340 )
>inability to move >Monitored intake >Because of from the
the left upper and and output and cerebral edema, relatives.
lower extremities specific gravity. fluid balance must
observed be regulated. Fluids
may be restricted if
>restlessness the patient has
noted significant increase
in ICP. (Nursing Care
>dependent and Plan, 6th edition,
Gulanick/Myers pg.
unable to
562)
participate in
activity
>Helps the client in
>Assisted the client
performing ADL’s.
>difficulty in in repositioning
(Nursing Care Plan, 6th
turning herself. edition, Gulanick/Myers
pg. 562)

>Provided safety >Enhances safety.

(Nursing Care Plan, 6th
measures such as
edition, Gulanick/Myers
putting pillow on
pg. 562)
bedside of the
patient to prevent
fall.
>Active ROM
>Taught perform increases muscle
active ROM mass, tone and
exercises on strength and
unaffected limbs improves cardiac
within levels of and respiratory
patient’s tolerance. functioning. (Nursing
Care Plan, 6th edition,
Gulanick/Myers pg.
563)

>A voluntary
>Performed passive
muscle will lose
ROM in affected
tone and strength
limbs at least three
and becomes
to four times daily.
shortened from
Exercises are done
reduced range of
slowly to allow the
motion or lack of
muscles time to
exercise. (Nursing
relax, and support
Care Plan, 6th edition,
the extremity above Gulanick/Myers pg.
and below the joint 563)

to prevent strain on
joints and tissues.
Stopped point when
pain and resistance
is met. >Reduces fatigue
and maximizes

>Scheduled energy production.

(Nursing Care Plan, 6th
activities with
edition, Gulanick/Myers
adequate rest
pg. 563)
periods during the
day.

>Prolonged
immobility and
>While the client is impaired
in bed, the following neurosensory
steps were function can cause
performed to permanent
maintain alignment: contractures.
(Nursing Care Plan, 6th
edition, Gulanick/Myers
pg. 564)
 >This measure
helps prevent foot
drop. (Nursing Care
a. Used pillows Plan, 6th edition,
Gulanick/Myers pg.
to serve as
564)
footboard.

>This measure
prevents hips
flexion contractures.
b. Avoided
(Nursing Care Plan, 6th
prolonged edition, Gulanick/Myers
periods of pg. 564)

sitting or lying
in the same >This measure

position. prevents shoulder

contractures.
(Nursing Care Plan, 6th
c. Changed
edition, Gulanick/Myers
position of pg. 564)
shoulder
joints every 2 >This measure
hours. prevents flexion
contracture of the
 d. Used a pillow neck. (Nursing Care
when on Plan, 6th edition,
Gulanick/Myers pg.
Fowler’s
564)
position
placed on the
back of the
>This measure
head.
prevents internal
rotation and
e. When client
adduction of the
is in lateral
femurs and hip and
position,
also internal
placed
adduction of
pillows to
shoulder. (Nursing
support the
Care Plan, 6th edition,
leg from groin Gulanick/Myers pg.
to foot and a 564)

pillow to flex
the shoulder
and elbow >Prolonged bed
slightly. rest can cause a
sudden drop in
>Provided blood pressure
(orthostatic
progressive hypotension) as
mobilization by blood returns to
maintaining head of peripheral
bed at least 30 circulation. (Nursing
degree angle and Care Plan, 6th edition,
Gulanick/Myers pg.
assisted the client
565)
slowly from lying to
sitting position.
>This position
promotes venous
drainage from the
brain and
decreases ICP.
>Kept the patient’s
(Nursing Care Plan, 6th
head and neck in edition, Gulanick/Myers
neutral position pg. 565)

>Frequent
stimulation of the
patient increases
brain activity and
ICP. Clustering care
>Avoided activities in a short
unnecessary care period of time also
activities. increases ICP.
(Nursing Care Plan, 6th
edition, Gulanick/Myers
pg. 565)