NURSING CARE PLAN #1

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Impaired Short term: Independent: Short term:
verbal At the end of 1. Identify 1. To determine At the end
communicatio 1week, the physiological of the impacting of 1 week,
n r/t patient will be neurological conditions such the patient
Objective: intubation able to relate conditions as severe was able to
>Disorientati findings of shortness of relate
on to person, decreased breath, facial findings of
space and frustration with trauma, decreased
time communication neuromuscular frustration
weakness and with
stroke. communicati
on
2. Advise other 2. Minimizes
healthcare clients
providers of clients frustration and
communication promote
Long term: deficits and needed understanding Long term:
At the end of 1- means of At the end
2weeks, the communication of 1-2weeks,
patient will be such as writing pad, the patient
able to establish signing, yes/no was able to
methods of responses, establish
communication in gestures, and methods of
which needs can picture board communicati
be addressed on in which
3. Obtain a written 3. When writing is needs can
translation or not possible or be
picture chart client speaks a addressed
different
language than
that spoken by
healthcare
provider.

4. Facilitate hearing 4. To obtain

and vision necessary needs
examinations

5. Provide 5. To maintain
environmental contact with
stimuli, as needed reality
Dependent/Collaborat
ive:
1. Identify 1. Timely
signs/symptoms treatment may
requiring prompt prevent
medical progression of
evaluation/interven problem
tion
2. Involve family in 2. Enhances
plan of care as participation
much as possible and
commitment to
communication
with loved one
 NURSING CARE PLAN #2

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Risk for Short term: Independent: At the end
aspiration r/t At the end of 4 1. Identify at-risk 1. To determine of 4 hours of
reduced level hours of nursing clients according when observation nursing
of intervention the to condition or may be required intervention
Objective: consciousness patient will be disease process the patient
Presence of able to, was able to
endotracheal experience no experience
intubation aspiration as 2. Monitor vital 2. To note response no
tube evidenced by signs frequently to activities and aspiration as
noiseless interventions evidenced
respirations; clear by noiseless
breath sounds; respirations;
clear, odourless clear breath
secretions sounds;
3. Assess urine for 3. Aspiration clear,
age-related risk pneumonia is more odourless
factors common in old secretions
potentiating risk individuals and
of aspiration. commonly occurs
Long term: with impaired Long term:
At the end of 1- airway defense At the end
2weeks, the mechanisms of 1-2weeks,
patient will be the patient
able to display was able to
hemodynamic 4. Assess clients 4. Helps determine display
stability ability to effectiveness of stabilized
swallow protective vital signs
mechanisms and was
trans-out
5. Suction the 5. To clear from ICU.
patient as secretions while Goal was
needed reducing met.
potential for
aspiration of
secretions.
Dependent/Collabor
ative:
1. Ascertain that 1. To reduce risk of
feeding tube is aspiration
in correct
position.
 NURSING CARE PLAN #3

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Self-care Short term: Independent: At the end
deficit r/t At the end of 4 1. establish rapport 1. To promote of 4 hours,
musculoskelet hours of nursing cooperation the patient
al impairment intervention, the 2. monitor vital signs was able to
Objective: secondary to patient will be 2. To have able to
CVA able to identify baseline data identify
personal personal
resources that 3. Assess for type 3. Provides data resources
can provide and severity of regarding that can
assistance and be immobility mobility and provide
able to verbalize impairment, ability to assistance
knowledge of muscle flaccidity, perform and be able
health care spasticity and activities with to verbalize
practices. coordination, in limitations knowledge
ability to walk, sit, without injury of health
Long term: move in bed or frustrations. care
After 3 days of practices.
nursing
intervention, the 4. Passive ROM to all 4. Promotes Long term:
patient will be limbs and progress circulation, At the end
able to to assistive and muscle tone, of 3 days,
demonstrate then active ROM joint flexibility, the patient
techniques/ in all joints four prevents was able to
lifestyle changes times a day contractures demonstrate
to meet self-care and weakness techniques/
needs lifestyle
5. use assistive 5. Provides safe changes to
devices as support for meet self-
appropriate for immobility and care needs
ambulation, other self-care
clothing with activities to
zipper closures, promote
suction cups on independence.
personal hygiene
articles for brushing
teeth, combing
hair, clothing that
is easily managed
to dress and
undress
Dependent/Collabora
tive:
1. Collaborate in 1. To enhance
treatment of clients
underlying capabilities,
conditions maximize
rehabilitation
potential.

2. Administer fluids, 2. To promote

electrolytes, optimal blood
nutrients and flow, organ
oxygen, as perfusion, and
indicated function
 NURSING CARE PLAN #4

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Risk for Short term: Independent: Short term:
electrolyte At the end of 1. Assess for the 1. This will At the end
imbalance r/t 8hours, the signs of provide a of 8hours
impaired patient will be dehydration data that the patient
Objective: regulatory able to be free of including skin could be was free of
Hemorrha mechanisms complications turgor, oral used to complicatio
gic stroke secondary to resulting from mucosa, etc. evaluate the ns resulting
Unilateral CVA electrolyte proper from
weakness imbalance intervention electrolyte
Episodes that the imbalance
of SOB client
Long term: needs.
At the end of 1- Long term:
2weeks, the 2. Encourage the 2. To reduce At the end
patients lab client to the dryness of 1-
results will be at increase the of the oral 2weeks, the
normal range. fluid intake. mucosa patients lab
results are
3. To within
3. Monitor I & O determine if normal
and IV fluids IV fluid and ranges.
electrolyte
replacemen
t are
needed

4. Keep a quiet 4. To reduce

environment stress and
and calm anxiety
activities.

5. Provide health 5. To promote

teachings on awareness
avoidance of on related
dehydration factors

Dependent/Collaborat
ive:
1. Consult with 1. Learning
dietitian or how to
nutritionist for incorporate
specific foods that
teaching increase
needs. electrolyte
increases
clients self-
sufficiency
and
likelihood of
success.
 NURSING CARE PLAN #5

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Activity Short term: Independent: Short term:
Intolerance r/t At the end of 1 1. Establish 1. To At the end
generalized week, the rapport promote of 1week,
weakness patient to will be cooperatio the patient
Objective: secondary to able to n was able to
Right CVA participate participate
hemiplegi willingly on 2. Monitor vital 2. To have a willingly on
a necessary/desire signs baseline necessary/d
d activities. data esired
activities.
Long term: 3. evaluate 3. Provide
At the end of 1- current comparativ Long term:
2weeks, the limitations e baseline At the end
patient will be (degree of data of 1-2weeks,
able to patient deficit in light the patient
will be able to of visual status) was able to
demonstrate a patient will
decrease in 4. assess cardio 4. To note be able to
physiologic signs pulmonary progress of demonstrate
of response to fatigue a decrease
intolerance(HR,B physical in
P remain within activity, physiologic
normal range) changes BP signs of
intolerance(
5. assist patient 5. To protect HR,BP
with activities from injury remain
within
Dependent/Collaborati normal
ve: range)
1. Set goals with 1. To sustain
patient and SO activity
for level
participation in
activities and
position
changes.
 NURSING CARE PLAN #6

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Impaired skin Short term: Independent: Short term:
integrity r/t At the end 4 1. Ascertain attitudes 1. Identifies At the end
immobility hours, the of individual/SO(s) areas to be of 1week,
patient to will be about condition. addressed in the patient
Objective: able to maintain teaching plan was able to
Right optimal nutrition and potential maintain
hemiplegi and physical referral optimal
a well-being. needs. nutrition
2. Inspect skin in 2. To monitor and physical
Long term: daily basis, progress of wound well-being.
At the end of 1- describing lesions healing.
2weeks, the and changes Long term:
patient will be observed. At the end
able to of 1-2weeks,
participate in 3. Keep the area 3. To assist bodys the patient
prevention clean/dry, natural process was able to
measures and carefully dress of repair participate
treatment wounds, support in
program incision prevention
measures
4. Avoid use of 4. Moisture and
plastic material potentiates skin treatment
and remove wet breakdown program
linens promptly

5. Encourage early 5. Promotes

ambulation circulation and
reduces risks
associated with
immobility

Dependent/Collaborati
ve:

1. Assist client to learn 1. To control

stress reduction and feelings of
alternate therapy helplessnessand
techniques deal with situation