SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Nursing Care Plan
SUBMITTED BY:
CABAYA, EMILYNE JOY M.
BSN 4B-1
SUBMITTED TO:
Mr. Rhoel Abubo
Clii!"l I#$ru!$or, B%& MED'
(ATIENT)S (RO*ILE:
Name: Timpac, Elsie
Address: Kapangan, Benguet
Age: 75 years old Birthdate: May 9,19!
"ender: #emale Marital $tatus: %ido&ed
'ccupation: #armer
(eligion: (oman )atholic *ate o+ Admission: $eptem,er 5,-.1/
*iagnosis: )ere,ro0ascular *isease Transient 1schemic (ight Mid )ere,ral Artery , 2ypertension 11 )
&ISTORY:
)hie+ )omplaint: 3e+t sided &ea4ness
2istory o+ 5resent 1llness:
'ne hour 5rior to admission, patient &as &ell ,ut &as suddenly +ell +rom her le+t side a+ter +arming66 No medications ta4en6
No associated signs and symptoms such6 5atient &as noted to ha0e le+t sided &ea4ness and ina,ility to speech6 Thus, signi7cant
others prompted t o see4 consult6 *ue to history o+ +all, loss o+ consciousness, le+t sided &ea4ness and ina,ility to spea4, patient
&as su,se8uently admitted
5ast medical 2istory:
*ate o+ admission 2ospital *iagnosis Medications
May -.1/ )hinese 2ospital 9nrecalled 9nrecalled
5atient is a 4no&n hypertensi0e6 $he has maintenance medication ,ut signi7cant other cannot recall names o+ medication
#amily 2istory:
There is a +amily history o+ hypertension, dia,etes mellitus, heart disease and asthma6 No +amily history o+ cancer,
tu,erculosis, goiter6
$ocio:en0ironmental:
5atient li0es in a +amily compound in Bua, Tuding6 $he li0es alone in her ,ungalo& type o+ house6 5atient is not a cigarette
smo4er and alcohol drin4er
3ist o+ 5rioriti;ed 5ro,lems:
5ro,lem (an4 <usti7cation
a6 Acti0ity intolerance
related to neuromuscular impairment
b. Impaired physical mobility
related neuromuscular
Actual 1t &as ran4ed as the = 1 prioriti;ed pro,lem since it a>ects his A*3
li4e ,rushing, going to the )(, and ta4ing a ,ath6 %ith these also, it
greatly a>ects the 1
st
and -
nd
le0el o+ needs &hich is physiologic and
sa+ety in Maslo&?s 2ierarchy o+ needs6 Acti0ities o+ daily li0ing are
impairment
1.
also 0ery important ,ecause these are part o+ the 1/ ,asic needs
according to @irginia 2enderson6These aciti0ities o+ daily li0ing are
also included in 2enderson?s theory so it must ,e prioriti;ed since
theses are acti0ities +or client assistance or these are ,asic human
needs6 $ince the patient &as diagnoses to ha0e )@* T1 (M)A
territory, the right part o+ the ,rain is ,eing a>ected so the le+t parts
o+ the ,ody &as paraly;ed6 There+ore, the patient cannot do his
aciti0ities o+ daily li0ing6 $o she is dependent to the signi7cant
others and to the nurse6
2. Self Care Defcit related to
neuromuscular impairment
Actual This must ,e prioriti;ed neAt since it concerns the sel+ o+ the
patient6 1na,ility to pro0ide care to the patient may lead to +urther
pro,lems6 This is prioriti;ed 7rst ,ecause the patient is &holly
compensatory dependent to the nurse B*orothea 'rem?s $el+ )are
*e7citC6 $el+ )are is the regulation o+ human +unctioning and
de0elopment to maintain li+e, health and &ell ,eing6 %e must
pro0ide the patient sel+ care ,ecause she is una,le to do so6
3. Risk for aspiration related to
neuromuscular impairment
Risk for Impaired Swallowin
related to neuromuscular
impairment
5otential Although this is a ris4 pro,lem, it should ,e prioriti;ed since this
may cause harm to the patient6 According to A,raham Maslo&, the
second le0el o+ human needs is sa+ety and security6 %e must ensure
client?s sa+ety to ,e a,le to a0oid harm and +urther pro,lems6 $a+ety
is also part o+ 2enderson?s ,asic needs and according to A,dellah
&e should promote therapeutic en0ironment to our patients6
/6 1mpaired 0er,al and &ritten
communication related to
neuromuscular impairment
Actual Although it is an actual pro,lem 1 prioriti;ed it as last since it &ill
ta4e time to regain the patient?s communication6 Also, &e cannot do
it &ithin days o+ nurse: patient interaction6
56 (is4 +or 9nilateral neglect
related to le+t hemiplegia o+ )@A
o+ right 2emishphere
5otential 1t is prioriti;ed last ,ecause it is a ris4 pro,lem and &e cannot
resol0e it in days inter0entions6 1T &ill ta4e time +or patient?s
reco0ery6
N9($1N" )A(E 53AN
A$$E$$MENT B(1E#
ED53ANAT1'N '#
T2E 5('B3EM
"'A3$ AN*
'B<E)T1@E$
1NTE(@ENT1'N$ (AT1'NA3E E@A39AT1'N
$: Ehindi niya
maigala& iyong
le+t niyaF as
0er,ali;ed ,y
&atcher
',Gecti0e:
H&ith le+t sided
&ea4ness
H +unctional le0el
as /: dependent
H ")$ o+ 1.BM:!,
@:1, E:C
HMuscle strength:
H&ith intact and
patent Nasogastric
tu,e
H&ith intact 1#)
connected to
hospicare drain
,ag draining to
am,er yello&
colored urine6
A state in &hich an
indi0idual has
insuIcient
physiological or
psychological
energy to endure
or complete
re8uired or desired
daily acti0ities6
Most acti0ity
intolerance is
related to
generali;ed
&ea4ness and
de,ilitation
secondary to acute
or chronic illness
and disease6 Motor
de7cits are the
most o,0ious
e>ect o+ stro4e6
$ymptoms are
caused ,y the
destruction o+
"oals: a+ter days
o+ nursing
inter0entions The
client &ill ,e a,le to
increase strength o+
the a>ected
compensatory ,ody
part
',eGcti0es:a+ter /
hours o+ nursing
inter0entions the
client &ill ,e a,le
to :
a. Demonstrate
absence of
complications
such as
aspiration!
labored
breathin
*D:
Assess +unctional
a,ilityJeAtent o+
impairment initially
and on a regular
,asis6 )lassi+y
according to .K/
scale
1denti7es
strengthsJde7ciencies
and may pro0ide
in+ormation regarding
reco0ery6 Assists in
choice o+
inter0entions, ,ecause
di>erent techni8ues
are used +or Laccid
and spastic paralysis6
Assess
"lasgo&)oma
$cale
To note thestatus o+
the patient
Assess muscle
strength
To identi+y motor
response o+ the patient
Assess patientMs
le0el o+ mo,ility6
"ids in defnin what
patient is capable of!
which is necessary
before settin realistic
oals.
H)T scan (esults
re0eals: acute
in+arct in0ol0ing
the right +ronto
parietal lo,e,
(M)A territoryN
mild temporal lo,e
atrophy, ,ilateralN
atherosclerotic
middle cere,ral
arteries6
Haphasic
H0ital signs: B5:
1/.J9. 5(: O-, ((:
1!, T:!6O)
Nursing *iagnosis:
Acti0ity
1ntolerance
(elated to
Neuromuscular
1mpairment
1mpaired physical
mo,ility related to
neuromuscular
impairment
motor neurons in
the pyramidal
path&ays Bner0e
7,ers in the ,rain
and passing
through the spinal
cord to motor
tract6C Mobility is
also related to body
changes from aging.
Loss of muscle
mass, reduction in
muscle strength and
function, joints
becoming stiffer and
less mobile, and gait
changes affecting
balance can
significantly
compromise the
mobility of elder
patients. Mobility is
paramount if elder
patients are to
maintain any
independent living.
Restricted
movement affects
the performance of
most activities of
daily living (ADLs).
lderly patients are
also at increased
ris! for the
TA: 1ndependent:
)hange positions
at least e0ery - hr
Bsupine, sidelyingC
and possi,ly more
o+ten i+ placed on
a>ected side6
(educes ris4 o+ tissue
ischemiaJinGury6
A>ected side has
poorer circulation and
reduced sensation and
is more predisposed to
s4in
,rea4do&nJdecu,itus6
*o passi0e ('M to
all eAtremities
Minimi;es muscle
atrophy, promotes
circulation, and helps
pre0ent contractures
and ischemia6
Massaged any
reddened areas
)irculatory stimulation
may pre0ent s4in
,rea4do&n and
decu,itus ulcer
de0elopment
complications of
immobility.
5lace pillo& under
aAilla to a,duct
armNEle0ate arm
and handN
5re0ents adduction o+
shoulder and LeAion o+
el,o&65romotes
0enous return and
helps pre0ent edema
+ormation6
Assist in doing
A*3$
To protect client +rom
inGury
Educati0e:
1nstruct so to do
passi0e ('M
Minimi;es muscle
atrophy, promotes
circulation, and helps
pre0ent contractures
and ischemia6
Encouraged $' to
turn patient
(educes ris4 o+ tissue
ischemiaJinGury6
A>ected side has
poorer circulation and
reduced sensation and
is more predisposed to
s4in
,rea4do&nJdecu,itus6
Nursing )are plan =-:
A$$E$$MENT B(1E#
ED53ANAT1'N '#
T2E 5('B3EM
"'A3$ AN*
'B<E)T1@E$
1NTE(@ENT1'N$ (AT1'NA3E E@A39AT1'N
$: Ehindi niya
maigala& iyong
le+t niyaF as
0er,ali;ed ,y
&atcher
',Gecti0e:
H&ith le+t sided
&ea4ness
H +unctional le0el
as /: dependent
H ")$ o+ 1.BM:!,
@:1, E:C
Motor de7cit are the
most o,0ious e>ect o+
stro4e6 $ymptoms are
caused ,y destruction
o+ motor neurons in
the pyramidal
path&ays Bner0e 7,ers
in the ,rain and
passing through the
spinal cord to the
motor tract6C 'ne o+
those symptoms could
,e ina,ility to per+orm
A*3$6i+ the patient is
una,le to do A*3s she
cannot ,e a,le to do
"oals: a+ter days
o+ nursing
inter0entions The
client &ill ,e a,le to
increase strength o+
the a>ected
compensatory ,ody
part
',eGcti0es:a+ter /
hours o+ nursing
inter0entions the
client &ill ,e a,le
*D:
Assess +unctional
a,ilityJeAtent o+
impairment initially
and on a regular
,asis6 )lassi+y
according to .K/
scale
1denti7es
strengthsJde7ciencies
and may pro0ide
in+ormation regarding
reco0ery6 Assists in
choice o+
inter0entions, ,ecause
di>erent techni8ues
are used +or Laccid
and spastic paralysis6
Assess a,ility to do
A*3s
To note i+ the patient
may only require
assistance with some
self-care measures.
HMuscle strength:
H&ith intact and
patent Nasogastric
tu,e
H&ith intact 1#)
connected to
hospicare drain
,ag draining to
am,er yello&
colored urine6
H)T scan (esults
re0eals: acute
in+arct in0ol0ing
the right +ronto
parietal lo,e,
(M)A territoryN
mild temporal lo,e
atrophy, ,ilateralN
atherosclerotic
middle cere,ral
arteries6
Haphasic
H0ital signs: B5:
1/.J9. 5(: O-, ((:
1!, T:!6O)
Nursing *iagnosis:
Acti0ity
1ntolerance
(elated to
Neuromuscular
1mpairment
ta4e care o+ her sel+
to :
a. Demonstrate
absence of
complications
such as
aspiration!
labored
breathin
Assess
patient's need
for assistive
devices
To increase
independence in ADLs
performance
TD:
)hanged clients
clothing, ,ed linens
and diaper
To promote com+ort
*o patient?s A*3$
such as assisting in
+eeding, com,ing,
positioning, &iping
+ace
5atient is &holly
compensatory in doing
A*3s
E*A
1nstructed $' to
position patient
com+orta,ly
To promote com+ort
1nstructed $' to do
A*3$ os patient
5atient is una,le to do
so and is &holly
compensatory
1mpaired physical
mo,ility related to
neuromuscular
impairment
Encouraged $' to
turn patient
(educes ris4 o+ tissue
ischemiaJinGury6
A>ected side has
poorer circulation and
reduced sensation and
is more predisposed to
s4in
,rea4do&nJdecu,itus6
Re+ere!e#
*oenges, M6, Moorhouse, M6, P Murr, A6 B-..!C6 #ursin Care $lans% &uidelines for Indi'iduali(in Client Care "cross the )ife Span.
5hiladelphia: #6A6 *a0is )ompany 6
"ulanic4, M6, P Myers, <6 B-.11C6 #ursin Care $lans . 1llinois: Mos,y 6
5orth, )6, P Mat7n, "6 B-..OC6 $athophysioloy% Concepts of "ltered *ealth States. 5hiladelphia: 3ippincott %iliams And %il4ins 6

Impaired 'erbal and
written communication
related to
neuromuscular
impairment
(is4 +or aspiration
related to
neuromuscular
impairment
(is4 +or 1mpaired
$&allo&ing related to
neuromuscular
impairment
$el+ )are *e7cit
related to
neuromuscular
impairment
Acti0ity intolerance
related to
neuromuscular
impairment
6 1mpaired physical
mo,ility related
neuromuscular
impairment