Nursing Care Plan

Cues Subjective: The client verbalized: -“Nahihirapan talaga ako maglakad lalo na dito sa kaliwang paa ko” -“mga 5 out of 10 parin yung sakit na ramdam ko pag naglalakad ako” Objective: -In the nursing chart, the client is diagnosed to have Intracerebral Hemorrhage at the ® upper medial frontal lobe -there is (+) difficulty in ambulation -during the interview there is slight slurring of speech. Measurement: BP: 150/90 RR: 26 Nursing Diagnosis Activity Intolerance related to decrease blood flow Analysis A stroke is the rapidly developing loss of brain function(s) due to a disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood supply) caused by thrombosis or e mbolism or due to a hemorrhage. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech or inability to see one side of the visual field In the past, stroke was referred to as cerebrovascular accident or CVA, but the term "stroke" is now Goal and Objectives Goal: After 8 hours of proper nursing interventions, the client will be able to enhance activity tolerance. Objectives: After 30 minutes of nursing intervention and health teachings: Developmental: -The client will understand the importance of ROM exercises. -Explain to the client the importance and good effect of ROM exercises. Range of motion exercises help keep your joints and muscles as healthy as possible. Without these exercises, blood flow and flexibility (moving and bending) of your joints can decrease. Joints, such as your knees and elbows, could become stiff and locked without range of motion exercises.
(http://www.family-friendlyfun.com/therapy/passiverange-motion.htm)

Interventions

Rationale

Evaluation

Goal was met.

The client was able to understand the importance of the ROM exercises.

-The client will be able to learn at least 3 out of

-Teach and demonstrate 5

To enhance

The client was able to learn 3

PR: 80

preferred.
(reference: http://en.wikipedia.org/ wiki/Stroke)

5 ROM exercises.

appropriate ROM exercises.

knowledge. To prevent or limit deterioration.
(NANDA, page64 )

out of 5 ROM exercises.

-The client will be able to demonstrate and participate in the ROM exercises.

-Instruct client to demonstrate appropriate ROM exercises to the client.

To be able to evaluate the acquired knowledge and skills on the given situational scenario.

The client was able to demonstrate ad participate in the exercises.

Supplemental: -Client’s safety will be ensured. - Take safety precautions

-To avoid injury.
(NANDA, page64)

To prevent occurrence of accidents and other complications.
(www.scribd.com/doc/2432 886/CardiovascularExercise-SafetyPrecaution)

The client’s safety was ensured.

-Client’s response will be monitored.

-Monitor the patient regularly for any signs of distress during the exercise. -Monitor and document vital signs.

To prevent overexertion.
(NANDA, page63)

The client’s response was monitored.

-Client’s vital signs will be monitored.

Vital signs are measures of various physiological statistics often taken by health professionals in order to assess the most basic body functions. Also to establish

The client’s vital signs was taken and recorded.

baseline data.
(http://en.wikipedia.org/wiki /Vital_signs)

Collaborative: -Due medications will be given. -Check physician’s order then administer drugs. To prevent any errors. Only privileged physicians and residents under their supervision can order medications.
(http://hcpc.uth.tmc.edu/pro cedures/volume2/chapter3/ treatment_services-32.htm)

Due medications were given.

-Any side effects of the drugs to the client will be monitored.

-Monitor any possible abnormal signs and symptoms.

To prevent further complications
(NANDA)

(If any) side effects was monitored.

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