Cues/Needs

Subjective:
di niya na
magalaw
masyado ung
kaliwang
parteng
katawan niya!
as verbalized
by the
informant.
Objective:
limited range
of motion
difficulty
turning
uncoordinated
movements
slowed
movement

Nursing
Diagnosis
Impaired
physical
mobility r/t
paresis

Rationale
Hemorrhagic
stroke usually
reproduces
extensive
residua function
loss and has the
slowest recovery
amongst all
types of stroke.
Bleeding often
produces spasm
of the cerebral
vessel and
cerebral
ischemia due to
blood outside the
vessels acts as
an irritant to the
tissues.
Their lumina
narrow, with
resultant
decreased blood
to the heart,
brain, and lower
extremities. As
the damage
continues, large
vessels may
become occluded
or may lead to
hemorrhage,
which cause
infarction of the
tissue supplied

Goals and
Objectives
After 4 hours of
nursing
intervention
the pt. will be
able to:
Demonstrate
techniques or
behaviors that
enable
resumption of
activities.
Maintain
position of
function and
skin integrity as
evidenced by
absence of
decubitus,
footdrop,
contractures
and so forth.
Maintain/increa
se strength and
function of
affected and /
compensatory
body part.

Nursing
Intervention
Independent:
Assess degree
of weakness in
both upper
and lower
extremities.
Assess ability
to move and
change
position to
transfer and
walk, for fine
muscle
movement and
for gross
muscle
movements.
Monitor skin
integrity for
areas of
blanching or
redness as
signs of
potential
breakdown.
Change
position of
patient atleast
2hours
keeping track
of position

Rationale

There may be
differing
degrees of
involvement on
the affected
side.
Paralysis and
sensory loss are
contra lateral to
the side of the
brain affected
by the stroke.

Impaired
mobility
increases the
risk for skin
breakdown

Patient may not

feel increase in
pressure or
have the ability
to adjust
position. Loss of
motor control

Evaluation
After 4 hours of
nursing
intervention my
goal for my
patient was
partially met, as
evidenced by:
Demonstrating
techniques or
behaviors that
enables
resumption of
activities.
Maintaining
position of
function and skin
integrity as
evidenced by
absence of
decubitus,
footdrop,
contractures and
so forth,
Maintaing /
increasing
strength and
function of
affected and /
compensatory
body part.

by the vessel
that has been
scuffed off blood
supply .

Cues/Needs

Nursing
Diagnosis

Rationale

changes with a
turning
schedule.

Goals and
Objectives

Nursing
Intervention

can contribute
to abnormal
posturing.

Rationale

Evaluation

Subjective:
Parang wala
na ang
kaliwang
bahagi ng
katawan niya,
hindi na niya
ito masyado
magalaw kasi
nanghihina na
as verbalized
by the client.
Objective:

Unilateral
neglect
related to
neuromuscu
lar
impairment

People
experiencing
right sided CVA
will develop left
sided paralysis or
left sided hemi
paresis due to
cerebral artery
occlusion that
most commonly
develop neglect,
which would lead
them to failure to
feel stimulation
on the affected
side of the body.

Left sided
hemiparesis
Defects of left
visual field
Inadequate
self care
Lack of
positioning or
safety
precautions in
regard to the
affected side
Consistent
inattention to
stimuli on an
affected side

> Medical
Surgical Nursing;
Woods, et al.; pp.
371; 2nd ed)

After 2 days of
nursing
intervention
the pt. will be
able to move or
use weak
extremities
with assistance
from
functioning
extremities and
touches
affected side
during ADLs.

Independent:
Approach the
patient from
the unaffected
side.

As patient
becomes more
alert,
approach to
the affected
side.

Ensure a safe
environment
by placing a
call bell on the
clients
unaffected
side

Place all food

in small
quantities,
arranged
simply on
plate.

This decreases
the anxiety and
fear while the
patient is unable
to interpret the
whole
environment
This will
encourage the
patient to use
the affected
side of the body
Hemianopsia
limits the
patients ability
to see objects in
the affected
visual field.
Thats why you
have to put a
call bell to ask
for assistance
and to prevent
risk for falls.
This approach
diminishes
visual deficits.
Small quantities
make it easier
to delineate
foods because
of the space

After 2 days of
nursing
intervention the
pt. was able to
used weak
extremities with
assistance from
functioning
extremities and
was able to
touched affected
side during ADLs.

between food
items.

Attach a watch
or bright
bracelet to the
affected arm.
Encourage the
patient to
wash the
affected side
of the body
and to dress
the affected
side of the
body first.
Teach
compensatory
strategies
such as visual
scanning.

Draws the
patients
attention to the
affected side.
This approach to
ADLs increases
the patients
awareness of
the affected
side of the body.

To reduce
chance of injury
and increases
visual
awareness of
entire field of
vision.
(Ref: Nursing
Care Plans;
Gulanick, Myers;
pp. 568-569; 6th
ed)

Cues/Needs

Nursing
Diagnosis

Subjective:
Medyo malakas
akong
manigarilyo as
verbalized by the
patient.
Objective:
Smokes an
everage of 7
sticks a day

Altered health
maintenance
related to the
presence of
adverse
personal habit
specifically
smoking.

Rationale
Altered health
maintenance
reflects a change in
an individuals
ability to perform
functions
necessary to
maintain health or
wellness. The
individual may
already manifest
symptoms of
existing physical
ailment or displays
behaviors that are
strongly linked to
the disease.
Nursing Care
Plans: Nursing
Diagnosis and
Intervention
p. 31, 3rd Edition

Goals and
Objectives
After 4 hours of
nursing
intervention, the
patient should
describe positive
health
maintenance
behaviours as
evidenced by:
Verbalization of
the importance to
quit smoking
Understanding
the negative
effects of
smoking

Nursing
Intervention
Independent:
Help patient to
implement a
plan to quit
smoking
Choose an
approach to quit
smoking
Avoid
temptations or
situations
associated with
the pleasurable
effects of
smoking
Keep oral
substitutes
handy
Learn relaxation
techniques to
reduce urge

Instruct patient
that relapses
occur

Rationale

Having a plan or
guide is always a
good start.
Different
approaches
appeal to different
individuals
Avoidance of
temptation is
tantamount to the
avoidance of the
vice
Oral gratifications
helps reduce the
urge to smoke
Breathing
exercises help
release tension
and overcome the
urge to smoke.
Reviewing the
reasons for
quitting helps
avoid the vices
Nursing Care
Plans: Nursing

Evaluation
After 4 hours of
nursing
intervention,
positive health
maintenance
behaviors were
established as
evidenced by:
Verbalization of
strong willingness
to quit smoking to
improve health
condition

Diagnosis and
Intervention
p. 33, 3rd Edition