Nursing Care Plan

Cues Nursing Diagnosis

Scientific Explanation

Objective/ Planning

Implementation Rationale Expected Outcome

Subjective:

Objective:

decrease LOC

Abnormal flexion or extension

Headache

Altered pattern of breathing

weakness

Ineffective tissue perfusion: cerebral r/t occlusion of the brain artery.

Perfusion of the cerebrum is critical for survival and long-term outcome. Decreased cerebral blood flow may be secondary to thrombus, embolus, hemorrhage, edema, or spasm. This disrupts the oxygen and glucose that goes to the brain causing the brain tissue to die (infarct).

Plan:

After the provision of nursing care, the client will have improved cerebral perfusion.

-Assess general health status.

-Assess client and monitor V/S every 2 hours.

-Maintain client’s blood pressure within the range prescribed by the physician.

-Perform assistive/ active ROM exercises.

-Elevate the head of the bed 30

- To provide baseline data.

-To analyze for trends, and if the client is deteriorating neurologically, notify the physician.

-To maintain perfusion without promoting cerebral edema.

-Active exercises promote venous return and alleviates the effects of the stroke

-To promote circulation and

After nursing intervention, the client was able to improve communication abilities and express thoughts verbally.

degrees.

-Maintain the client’s head in a neutral position when sleeping.

-Administer medication as prescribed by the physician.

-Avoid valsalva maneuver, excessive coughing, vomiting, lifting, or use of the arms to change position.

-Promote quite, restful environment

increase gravitational blood flow.

-To improve venous drainage.

-Medications are used to improve cerebral tissue perfusion and decrease the risk for further thrombus formation.

-This increases intracranial pressure and may lead to ineffective cerebral tissue perfusion.

-Conserves energy, lowers oxygen tissue demand, and decrease intracranial pressure.

Cues Nursing Diagnosis

Scientific Explanation

Objective/ Planning

Implementation Rationale Expected Outcome

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

Impaired physical mobility r/t hemiplegia (left body).

Almost ll clients have some degree of immobility after stroke. In the early phses of stroke recovery, the client may be completely immobile nd need assistance just to turn in bed. Later in recovery, mobility may be hampered in one extremity only. This can cause by loss of muscle tone secondary to flaccid paralysis and reluctance to move because of the fear of self-injury or prolonged tissue.

Plan:

After the provision of nursing care, the client will be able to:

-maintain/increase strength and function of affected and / compensatory body part, and

-maintain skin integrity as evidenced by absence of decubitus ulcer, footdrop, contractures and so forth.

-Approach the client 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 client is unable to interpret the whole environment

This will encourage the client to use the affected side of the body

Hemianopsia limits the patient’s ability to see objects in the affected visual field. That’s 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

After nursing intervention, the client was able to maintain strength and function of affected area (left) and maintain skin integrity.

-Teach compensatory strategies such as visual scanning.

-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

easier to delineate foods because of the space between food items.

To reduce chance of injury and increases visual awareness of entire field of vision.

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

breakdown.

-Change position of client atleast every 2 hours keeping track of position changes with a turning schedule.

Client may not feel increase in pressure or have the ability to adjust position. Loss of motor control can contribute to abnormal posturing.

Cues Nursing Diagnosis

Scientific Explanation

Objective/ Planning

Implementation Rationale Expected Outcome

Subjective:

Objective

Poor muscle strength

Weak musclesGrade 4

Risk for injury: fall r/t poor muscle coordination and muscle weakness.

Most people who have strokes are in danger of falling, getting hurt. Almost 60 per cent of people who have a stroke experience one or more falls afterward.

Plan:

After the nursing interventions, the client will be able to maintain safety and prevent fall and injury.

-Monitored client frequently and at least every 2 hours during the night.

-Monitored for change in LOC and visual disturbances.

-Informed about a safety precautions and why they are needed.

-Assisted with self-care activities.

-Provided safety by placing pillow at the side of the pt and instructed

Frequent supervision reduces client anxiety and unsafe behavior and prevents unlikelihood of falls.

Changes may reflect cerebral bleeding.

Knowledge of potential problems can help to prevent injuries and accidents.

Prevents falls with resultant injury.

Reduces falls or risk of injury.

After the nursing interventions, the client maintained safety and injury-free.

caregiver to never leave the pt.

-Place items used by client within easy reach.

-Teach fall prevention strategies, involve client in problem solving.

-Collaborate with other health provider about safety measures to be used.

Stretching to get items from bedside tables that are out of reach can disrupt the client’s balance and contribute to falls.

To enhance client compliance.

To ensure pt safety during the course of treatment.