NURSING CARE PLAN

Pt name: R.Asperin Assessment Nursing Dx Subjective: Ine))e,ti2e tiss!e per)!si$n (,ere*ral+ Client said, r3t interr!pti$n $) namamanhid *l$$d )l$% !n" #anan" ($,,l!si2e dis$rder+ #ama #$, per$ as e2iden,ed * na"a"ala% #$ ri"ht arm n!m*ness naman &ha med $ hirap ln" a#$.' bjective! Arrh thmias (atrial )i*rillati$n+ S#in temperat!re ,han"es (*$d temperat!re is 36.- .C+ Oli"!ria ($!tp!t is -/0ml and inta#e is 1/0ml+

Inference CVA ,an *e ,a!sed * an $,,l!si$n in the *l$$d )l$%. 4his ,an lead t$ 5Oand the ,a!se )ail!re t$ n$!rish the tiss!es at the ,apillar le2el

AGE: 63 Goals Long term! A)ter 6 da s $) n!rsin" inter2enti$n, ,lient %ill *e a*le t$ dem$nstrate 7 per)!si$n Ex"ecte# outcome: N$rmal I3O (e.". 8/00:8/00+ 5 m$t$r resp$nse A*sen,e $) arrh thmia S$ort term! A)ter 1 hrs $) n!rsin" inter2enti$n, ,lient %ill *e a*le t$ parti,ipate in therape!ti, re"imen and t$ in,rease s#in and *$d temperat!re Ex"ecte# outcome: Ver*ali9ati$n $) !nderstandin" the ,$nditi$n S#in and *$d temperat!re is n$rmal Ver*ali9ati$n $) !nderstandin" $) %hen t$ ,$nta,t :C pr$2ider

Intervention In#e"en#ent! 8. Assess the ,lient )irst -. 4a#e n$te $) la* res!lts and 23s 3. Re2ie% $) dia"n$sti, st!dies d$ne 6. Determine 2$idin" patterns /. ;eas!re e&tremities< ,ir,!m)eren,e 6. ;eas!re I3O =. Ele2ate :O> espe,iall at sleep time 1. En,$!ra"e rela&ati$n ?. En,$!ra"e %arm dressin"s and pre2entin" e&p$s!re t$ ,$ld 80. Per)$rm health tea,hin" a*$!t: 4he si"ns and s mpt$ms $) the ,$nditi$n (paral sis, l$% s#in and *$d temp+ @hen t$ ,$nta,t :C pr$2ider (%hen s mpt$ms are "ettin" %$rst+ De"en#ent! 8. Administer appr$priate medi,ati$ns as $rdered

DIAGNOSIS: CVA Rationale Evaluation In#e"en#ent! Long term goals 8.4$ esta*lish "artiall% met: ,$mparati2e *aseline 4he pt is n$t a*le t$ )!ll -.4$ #n$% i) the pt<s dem$nstrate 7 per)!si$n ,$nditi$n is "ettin" as e2iden,ed * : *etter $r n$t S#in is still n$t %arm 3.4$ determine the t$ t$!,h (3/.? .C se2erit $) the *$d temperat!re+ ,$nditi$n Im*alan,ed I3O 6.4$ ,$mpare past )l!id ($!tp!t is 300ml and stat!s t$ the ,!rrent inta#e is ?00ml+ /.4$ identi) i) there is 7m$t$r resp$nse (5 edema n!m*ness+ 6.4$ m$nit$r )l!id Presen,e $) *alan,e arrh thmia =.4$ pr$m$te S$ort term goals ,ir,!lati$n and "artiall% met! 2en$!s draina"e 4he ,lient is a*le t$ 1.5 tiss!e O- demands parti,ipate $n the ?.4$ retain heat m$re therape!ti, re"imen as e))i,ientl 80. 4$ eA!ip ,lient %ith e2iden,ed * 2er*ali9ati$n $) adeA!ate #n$%led"e !nderstandin" $) the re"ardin" his ,$nditi$n, and %hen t$ ,$nditi$n ,$nta,t :C pr$2ider and De"en#ent! the ,lient d$es n$t ret!rn 8.4$ pr$m$te healin" t$ n$rmal temperat!re e))e,ti2el