Nursing Care Plan
Assessment Subjective: “Ng nagsimula ang panghihina ng kaliwang parte ng aking katawan ay hindi ko na maasikaso ang sarili ko” as verbalized by the patient Nursing Diagnosis Self care deficit related to neuromuscular impairment secondary to CerebroVascular infarction as evidenced by (+) leftsided body weakness, Limited Range of Motion with muscle strength of 3/5, requires help from others to do daily activities. Inference Hypertension Occlusion within vessels of the brain parenchyma Disruption of blood supply in the brain area Tissue and cell necrosis Destruction of Neuromuscular junctions Interruption in transporttation of electrical impulses to the neuromuscular receptors Left Sided Weakness of the body Planning Short term Goal: After 2 hours of nursing intervention the patient will be able to identify individual areas of needs and perform self-care activities within level of own ability as evidenced by proper hygiene and self independence. Intervention Independent: - Reviewed Medication regimen for possible effects on alertness, energy level, balance and perception. - Developed a plan regarding patient care with the patient and relatives - Demonstrated to the patient and relatives the right way of proper feeding, bedbathing, and giving medications. - Performed and demonstrated to the patient and relatives on how to do an activeassistive range of motion exercises. - Provided an adequate rest periods as well as comfort and safety measures to the patient. - to determine issue affecting ability of individual to participate in own care - to implement the right care and comfort for the patient Rationale Evaluation Short term Goal: After 2 hours of nursing intervention the patient are already able to identify individual areas of needs and perform self-care activities within level of own ability as evidenced by proper hygiene and self independence.
Objective: - (+) leftsided body weakness - Limited Range of Motion with muscle strength of 3/5 - Requires help from his live-in partner in order for him to sit, eat and drink medication. - Patient is unable to wash his body and put on clothes alone.
- to enhance patient knowledge and independence to do daily activities
- to increase the muscle strength and to prevent unilateral neglect
- To prevent further stress, fatigue and injury.