University of Perpetual Help System DALTA

COLLEGE OF NURSING
Alabang-Zapote Road Pamplona, Las Pias City
NURSING CARE PLAN

ASSESMENT
Subjective:
Nanghihina na
din ung
kaliwang parte
ng katawan niya
ung binti. As
verbalized by the
pts relative.
Weakness at
left lower
extremity.

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATION

Risk for injury

Cerebrovascular
related to altered disease is a disease
mobility
that involves a
secondary to
disruption of blood
CVD as
flow to the brain
evidenced by
resulting in a loss
left sided
or diminished brain
paralysis.
function. Clinical
manifestations may
include limited
ROM, decrease
muscle tone, and
lethargy.

Objective:

Lethargic
Slowed
movement
limited
ROM at left
lower
extermity of
the body
(grade 3)
Muscle

- Brunner &
Suddarth: Medical
& Surgical Nursing
12th Edition

GOAL AND
EXPECTED
OUTCOMES
After 4 hours of
nursing intervention the
patient will be able to
maintain safety from
injury
Demonstrate
behavior that
will protect self
from injury.

INTERVENTIONS

RATIONALE

EVALUATION

Perform
thorough
assessment
regarding safety
issues when
planning for
patient care

Failure to
assess and refer
the issue can
place the
patient needless
risk

Goal Met.
No occasion of
falls reported.

Assess patients
muscle strength,
gross and fine
motor
coordination

To prevent
injury and to
evaluate
activities the
patient cannot
tolerate

Modify
environment:

To promote and
maintain safety
to the patient

No report of
occasion of
injury

Maintain bed in
lower position
with wheels
locked
Ensure that
pathway to
bathroom is

University of Perpetual Help System DALTA

COLLEGE OF NURSING
Alabang-Zapote Road Pamplona, Las Pias City
paralysis at
right side of
the body
(grade 0)

unobstructed
and properly
lighted.
Instruct patient
to request
assistance as
needed
Provide
information
regarding
condition that
may result in
increased risk of
injury.

University of Perpetual Help System DALTA

COLLEGE OF NURSING
Alabang-Zapote Road Pamplona, Las Pias City

ASSESMENT
Subjective:
Hindi nya na
magalaw yang
kanang part ng
katwan nya eh,
paralyzed na kase
as verbalized by the
pt.s relative
Objective:

Difficulty in
ambulating
and moving
Slowed
movement
Muscle
paralysis at
right side of
the body
(grade 0)
Limited
ROM at left
lower
extremity
(grade 3)
Non-

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATION

Impaired
physical mobility
r/t right sided
body paralysis
and left lower
side body
weakness
secondary to
CVD as
evidenced by
inability
ambulating
without
assistance

Cerebrovascular
disease is a disease
that involves a
disruption of blood
flow to the brain
resulting in a loss
or diminished brain
function. As a
result, physical
movements are
affected. Clinical
manifestations
include limited
ROM, discomfort
upon movement
and decrease
muscle strength.

- Brunner &
Suddarth: Medical
& Surgical Nursing
12th Edition

GOAL AND
EXPECTED
OUTCOMES
After 4 hours of
nursing
intervention the
patient will be
able to:
Perform

necessary
activities
in
patients
maximal
capability
with the
proper use
of
assistive
devices
such as
wheelchai
r and
crutches.

INTERVENTIONS

RATIONALE

Goal partially Met:

The patient was
able to utilize the
use of wheelchair
during ambulation.

Use measures to
relieve pressures and
assist in maintaining
good body
alignment
Instruct to
Perform active
and passive
range of motion
exercises in all
extremities
including the
affected part

EVALUATION

To prevent
contractures

Turning pt. q 2
hrs.
Apply trochanter
roll at the hip
joint

To prevent
external rotation
of the hip joint

Place a pillow in
the axilla

To prevent
adduction of the
affected shoulder

University of Perpetual Help System DALTA

COLLEGE OF NURSING
Alabang-Zapote Road Pamplona, Las Pias City
ambulatory

Plan care with rest

periods between
activities

Perform musclestretching activities

in gentle, rhythmical
motions.
Protect from injury
by assisting patient
with activities and
providing assertive
devices as indicated
such as crutches,
walker or wheelchair

To reduce fatigue
and to provide a
plan for maximal
activity within the
patients ability
To improve
muscle strength

To provide safety
and improve
ambulating ability
of the patient

University of Perpetual Help System DALTA

COLLEGE OF NURSING
Alabang-Zapote Road Pamplona, Las Pias City

ASSESMENT

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATION

Anxiety related
to physiological
crises secondary
to CVD as
manifested by
verbalization of
feelings.

A feeling of
apprehension due
to threat to
physiological
aspect of a man.
Since patient is
experiencing
uneasiness towards
medical condition,
the psychological
aspect is also
altered.

GOAL AND
EXPECTED
OUTCOMES

INTERVENTIONS

RATIONALE

EVALUATION

Monitor vital
signs every 30
minutes.

To identify
physical
responses to
both emotional
and medical
condition.

Goal Met: The

patient was able
to decrease level
of apprehensions.

Allow
verbalization of
apprehensions.

To reduce level
of anxiety.

Clarify meaning
of feelings and
actions by
providing
feedback

To avoid any
misinterpretation
of feelings.

Provide accurate
information
about the
situation,
acknowledging
the degree of
information to be
given.

Provide a calm
and quiet

Subjective:
Di ko na
magalqw itong
katawan ko. As
verbalized by the
patient.
depressed
worried
Objective:

Lethargic
Unrelaxed
Tearfulness
Nonambulatory
Limited
ROM at left
lower
extremity
(grade 3)

Risk for
powerlessness
related to present
medical
condition
secondary to
CVD as
manifested by
verbalization of
feelings.
- Nurses Pocket
Guide 12th Edition

After 4 hours of
nursing intervention the
patient will be able to
be free from any
apprehensions.
Verbalized
ease of
depression

Increase feeling
of self worth

Helps client
identify what
is reality
based.

To reduce level
of anxiety.

University of Perpetual Help System DALTA

COLLEGE OF NURSING
Alabang-Zapote Road Pamplona, Las Pias City
environment

Reminded and
encouraged to
seek spiritual
anointment and
peace of mind to
God with respect
to her religion.
Encouraged to
communicate
with her family
in verbalization
of anxiety

Increase hope
and decreases
feeling of
vulnerability to
the patient.

Provides social
support