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NURSING CARE PROCESS

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING INTERVENTION RATIONALE EVALUATION

Subjective cues: “ Nahihirapan siyang umimik”, as verbalized by the relative. Objective cues: > non – verbal response when asked > difficulty of forming words noted > LOC - lethargy > GCS= 10

Impaired verbal communication related to alteration of motor speech area of the brain

A CVD, which may be caused by, hemorrhage, thrombus, embolism or vasospasm, can result in a local area of cell death, called infarct. It is caused by a lack of blood supply which is then surrounded by an area of cells that are secondarily affected. Since symptoms depend on the location of the stroke and size of the infarct, it could involve the brain’s Brocca’s area, which is

After 3 days of nursing interventions, the client will establish method of communication in which needs can be expressed.

>Monitored vital signs with emphasis to BP.

>Establishes baseline data for review of existing conditions. (Nursing
Care Plan, 6 edition, Gulanick/Myers pg. 565)
th

The client has established method of communication in which needs can be expressed as evidenced by :  “Salamat” as verbalized by the client.  Established eye contact while communicating with others  Used paper and pen to express needs

>Provided an atmosphere of acceptance and privacy through speaking slowly and in a normal tone, not forcing the client to communicate.

>Impaired ability to communicate spontaneously is frustrating and embarrassing. Nursing actions should focus on decreasing the tension and conveying an

primary responsible for >restlessness noted communication through facial expressions and speech. By causing damage to this area, the patient’s communicating skills are greatly altered and affected. >Taught techniques to improve speech by initially asking questions that client (Medical- Surgical Nursing,
vol.2,9th edition, Brunner & Suddarths, page 1259 )

understanding of how difficult the situation must be for the client.
(Nursing Care Plan, 6th edition, Gulanick/Myers pg. 565)

>Deliberate actions can be taken to improve speech. As the client’s speech improves, his confidence will increase and she will make more attempts at speaking. (Nursing
Care Plan, 6th edition, Gulanick/Myers pg. 565)

can answer with a “yes” or “no”.

>Used strategies to improve the client’s comprehension by using touch and behavior to communicate calmness and adding other non – verbal methods of as pointing or using flash cards for basic needs; using pantomime; or using paper and pen. >Involved the significant others in the plan of care.

>Improving the client’s comprehension can help to decrease frustration and increase trust. Clients with aphasia can correctly interpret tone of
Plan, 6th edition, Gulanick/Myers pg. 566)

communication such voice. (Nursing Care

>Enhances participation and commitment to plan. (Nursing Care
Plan, 6th edition,

Gulanick/Myers pg. 566)

>Imparts thought >Educated relatives to establish a method of communication through sign language. and answers the needs of the client with lessened difficulty. (Nursing
Care Plan, 6th edition, Gulanick/Myers pg. 566)