Notre Dame University

COLLEGE OF HEALTH SCIENCES

Cotabato City

NURSING CARE PLAN

Name of patient: Yolly Name of Students: Sinclair Abolencia,

Diagnosis: Stroke Isra Ayessa Angas, Abdulazis Bagua,
Joanna Mae Drilon, Junaida Tadz Kamensa,
Sahana Nanding, Anisa Macarimbang,
Florida Sabpa, Friscian Siong

Name of C.I.: Prof. Jeory B. Gutigulao, RN

Date: May 14, 2019

Human Response Nursing Diagnosis Cues Pathophysiological Basis Nursing Outcome

Pattern

M Impaired physical Subjective cues: A stroke occurs when the blood supply to the Within the shift, the patient
O mobility related to partial  severe headache brain is suddenly blocked or when a blood will be able to:
V paralysis secondary to  numbness and vessel in the brain ruptures. Deprived of oxygen, a. participate willingly in the
I stroke. weakness on face, nerve cells in the affected area of the brain can't performance of range of
N arms and legs on function and die within minutes. When this motion exercises
G one side of the happens, messaging between the brain and b. demonstrate a decrease in
body muscles may not work properly. physiological signs of
Paralysis is a common outcome of stroke, often intolerance
Objective cues: on one side of the body (hemiplegia). Paralysis
 unconscious may affect only the face, an arm or a leg, or it
 head injury may affect one entire side of the body and face.
Impaired physical mobility a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined
as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or
more extremities.

A cerebral vascular accident is another name for a stroke. It is damage to the brain caused by a disruption of the blood
supply to a part of the brain. This disruption of blood supply can be caused by a blood clot, or by a ruptured artery.

The symptoms of a cerebral vascular accident depend on which part of the brain is affected. Common symptoms may
include paralysis of a part of the body, loss of all or part of the vision, or loss of the ability to speak or to understand
speech.

A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. Risk factors
for stroke include old age, high blood pressure, previous stroke or transient ischemic attack (TIA), diabetes, high
cholesterol, tobacco smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of
stroke. It is the second leading cause of death worldwide.

Nursing Diagnosis for CVA - Stroke:

1. Ineffective Cerebral Tissue Perfusion

2. Impaired Physical Mobility.

3. Imbalanced Nutrition, Less Than Body Requirements.

4. Impaired Skin Integrity.

5. Impaired Verbal Communication

6. Disturbed Sensory Perception

7. Self-Care Deficit

8. Knowledge Deficit

No matter the type of stroke, acting fast and seeking treatment as quickly as possible is key to reducing the risk of
permanent brain damage.

The goals of stroke rehabilitation are to help stroke survivors live as independently as possible while adjusting to new
limitations.

Stroke physical therapists are able to stimulate affected muscles and nerves to maintain circulation and prevent stiffness,
then guide patients through the stages of stroke recovery as they relearn basic muscle movements.

The normal pulse for healthy adults ranges from 60 to 100 beats per minute.
Normal respiration rates for an adult person at rest range from 12 to 20 breaths per minute.
Normal blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80)
Elevated blood pressure is systolic of 120 to 129 and diastolic less than 80
Stage 1 high blood pressure is systolic is 130 to 139 or diastolic between 80 to 89
Stage 2 high blood pressure is when systolic is 140 or higher or the diastolic is 90 or higher