You are on page 1of 14

NURSING CARE PLAN

Patients Initials age/sex:
Diagnosis:

g. elimination. and ambulation Because  brush teeth and condition. 1991. the client  Obtained To aid in the brain caused voluntarily controlling will be able to: vital signs. constitutes the able to perform self-care Patients Initials age/sex: dressing/groomi activities of daily living. keeping body clean and well groomed and protecting the integument  Encouraged (Henderson. assessment and by a transient urinary and fecal  wash her entire face evaluation of ischemic attack discharge. of feelings. but insisted independence on the client  Spoke slowly For the patient to and clearly. gathering of to meet the need in independently. data. neurological hygiene and grooming.  Assisted patient in To increase performing patient’s self- daily hygiene esteem. patient’s or CVA. secondary to feeding oneself. functional impairment dressing and undressing. of poor cognition and clean them properly thinking. individual intercventions. After 2 hours of interruption of functional transfers (e. activities effectively  Assessed the To facilitate Diagnosis: ng related to Basic activities of daily within level of own degree of necessary living include: personal ability. Assessment Diagnosis Background Knowledge Planning Intervention Rationale Evaluation Any activity or task that Subjective: Self-care deficit: an individual undertakes Goal: Within the shift. 1960). the patient will be the student nurse: bathing / hygiene. comprehensive nursing blood supply in Getting out of bed). Objectives: level. be able to understand and comprehend the statements. the patient to decrease tartar wasn’t able to do the  get access to water  Established To facilitate activity and wasn’t able easily and NPI. assessment of patient’s condition and effectiveness of implemented procedures. . effectively. Objective: NURSING throughout the course of CARE PLAN After. interventions. verbalization To facilitate Abdellah. the day.

NURSING CARE PLAN Patients Initials age/sex: Diagnosis: .

 Discuss the To retain heat or importance of warmth preventing efficiently . will  Assist patient. After 2-3 deviations from or CVA.  Encourage use To decrease the of relaxation tension level techniques or exercises. the O2 supply going to Intervention. the brain is also impaired. there is a goal: Rapport nurse-patient Objective: cerebral tissue decrease in oxygen NURSING CARE PLAN After 2-3 days of therapeutic perfusion related supply which results in Nursing intervention. brain are impaired. Blood vessels individually appropriate signs baseline data disease process which function is to and to identify of transient supply blood to the objective: any other ischemic attack different parts of the After 5hrs. days of Nursing normal. Exercise The t issues may caution in have decreased using hot or sensitivity due to cold pads. the relationship Patients Initials age/sex: to vascular the failure to nourish the pt. Assessment Diagnosis Background Knowledge Planning Intervention Rationale Evaluation In cerebral tissue  Establish To establish Subjective: Impaired perfusion. be able to demonstrate in assuming To aid with Proper perfusion is behaviors which may semifowler’s proper perfusion needed in order to give improve proper position w/ or flow of blood adequate nourishment to circulation such as head midline. Thus. function well. the pt. provided. could aid in lowering the O2 tissue demand.  Administer medications as To probably ordered such decrease cardiac as workload and in antihypertensi maximizing ve or diuretics. ischemia. will demonstrate Diagnosis: occlusion tissues at the capillary increased perfusion as  Monitor Vital To obtain secondary to level. tissue perfusion Encourage quiet and To conserve restful energy which atmosphere. (circulation or he different parts of the compliance to health venous brain in order for it to management & therapies drainage).

 Assessed General To note for signs the brain’s neurons hemisphere Condition and symptoms caused by transient affectation causing Objective: the immobility After 3 hrs of  Provided positive ischemic attack or because of stiffness nursing intervention atmosphere to minimize CVA. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: Assessment Diagnosis Background Planning Intervention Rationale Evaluation Knowledge Activity Infarction on the Goal:  Established To gain patient’s Intolerance related right hemisphere has After 3 days of Rapport Trust to neuromuscular a contra lateral nursing intervention impairment manifestation of the patient will  Assessed V. of pain participate in The nervous system activities is made up of nerve  Provided ROM cells called neurons to promote exercises that serve as the circulation communication system of the body.S. To gain baseline secondary to either left side demonstrate data interruption of paralysis and/or increase in activity blood supply in weakness due to left tolerance. tolerance.  Give client They carry messages in the form of information that to sustain provides . of muscle and the patient will use frustration unability to mobilize identified  Promoted comfort due to the techniques to measure and manifestation of the enhance activity provide for relief to enhance ability to disease condition.

limited ability measures to repair themselves unlike other body tissues that is why nerve cells cannot be repaired if damaged due to injury or disease. demonstrating to prevent injuries Because neurons appropriate safety have. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: electrical impulses. evidence/differenc motivation The messages move e from one neuron to  Assist client in another to keep the learning and body functioning. .

Applying Monitor I&O To have a baseline skin data regarding moisturizer input and output c. disease condition. minimizing the risk immobility in the skin may Monitor v/s To obtain baseline secondary to harbor Objective: data neuromuscular microorganisms that After 4 hr of nursing The pt shall have impairment caused may invade the intervention the Assess pt’s general To note for the been free from risk. Turning the patient from side to side b. a. pt therapeutic trust and took actions related to prolonged the body against will be free of the relationship cooperation regarding bed rest and infection. Ischemic attack. by the blood normal processing patient’srelatives will condition etiology or insufficiency in the of the body. Provides comfort d. Any break from skin breakages. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: Assessment Diagnosis Background Planning Intervention Rationale Evaluation Knowledge Risk for Impaired The skin is the Goal: Establish To gain pt’ and SO’s The pt shall have skin integrity baseline defense of After 3 days of NI. day Arrange bed linens To prevent increase pressure and reduce risk for skin breakage . Flattening all Encourage To maintain the linens increase OFI to al hydration status least 2-3 liters per . which take actions regarding precipitating brain’s neurons due may inflict or minimizing the risk factors that can to transient aggravate the pt’s through: aggravate the risk.

To maintain skin including skinfold moisture area. Use hydration and moisturization on all at-risk surfaces. Assist client in To prevent pressure changing positions ulcer every two hours Provided Health To lessen the pt’s feeling of anxiety information regarding the occurring problem To promote rest and Provided pt’s wellness conducive . NURSING CARE PLAN Patients Initials age/sex: Diagnosis: Encourage and To maintain good assist client to blood circulation active and passive ROM exercises Encourage rest To promote opportunities optimum level of functioning Provided comfort To let patient feel measures and safe and safety comfortable Carefully wash and pat dry skin.

NURSING CARE PLAN Patients Initials age/sex: Diagnosis: environment for resting To promote Encourage client adequate to have balanced nourishment. For proper Monitor and replacement of fluid Regulate IVF as losses. per doctor’s order . diet especially with increased intake of vitamin C and Protein.

overhead trapeze transfer discontinuing the patient will Explain toand the roller pad treatment. deficiency OBJECTIVE: movement andenvironment blood supply tointervention. of side rails. antibiotics of fluid andthere isenergy a need of nutritious food production . has poorer strength and willingness damages the brain 3. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: Assessment Diagnosis Background Planning Intervention Evaluation Knowledge Rationale SUBJECTIVE: Impaired Limitation in Short Term:  Vital signs taken To provide physical independent At the end of the and recorded baseline data Assessment mobility Diagnosis Planningshift the patientIntervention purposeful physical Rationale Evaluation SUBJECTIVE: related to Riskmovement for Short Term: of the would be able Note to for risk To evaluate  Assessed extent To identify neuropathy as Infection body of one moreAfter 30 increase level factors presence of of impairment strength manifested byrelated to extremities.dependent to physical Long term: precautions immobility. activity. minutes Sudden of function from 2 torelated 0.independent limited range of areas of the brain family1-of use al exposure the theof Observe for effectiveness Reduces risk of patient will be  Assisted localized sign of theraphy patient motion. due to CVA result equipment tissues impaired able to 2. sensation to assistancerelatives severity that leads about the skin breakdown 4.use of of infection to impaired cerebral to reposition at self ischemia. exercise. from and sleep relatives the signs and necessity of To promote  Encourage well being symptoms of taking To assist if adequate intake maximize infection. coordination and metabolism whichverbalize insertionevery two hours personal affected parts decrease muscle permanently understanding assistancesites.use of circulation and secondary to to follow tissue and produce Administer and equipment CVA prescribed and personal focal neurologic instruct reduce deficit varyingregimen.risk of changes and To promote optimal intervention. After 5 days of regarding To inform Forthe position Long term:  Instructed used relatives the nursing regimen. the To determine OBJECTIVE: 0. be freerest. to infection slowed increase interruption ofnursing where in infection.

of environment to reduce incidence of infection. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: Review avoidance or environmenta modification l factors. To minimize Before and after the spread of giving care to pathogens the client observe proper hand washing techniques. Assessment Diagnosis Planning Intervention Rationale Evaluation SUBJECTIVE: Risk for Short term: Assess cough A depressed Aspiration r/t After 8 hours of and gag coughand depressed nursing reflex gag reflexes cough and intervention the increases the risk for OBJECTIVE: gag reflex patient will be aspiration free from aspiration as evidenced by A decreased Monitor level of level of Long Term: consciousnes consciousnes After 8 hours of s s is a prime nursing factor for intervention the aspiration patient will be free from Auscultate Decreased GI motility aspiration as bowel sounds increases the .

. sides Comatose patients nedd frequent turning to facilitate drainage of Check secretions. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: evidenced by to evaluate risk of presence of gag bowel motility aspiration reflex because foods and fluids accumulate in the Assess stomach pulmonary status for Aspiration of clinical small evidence of amounts can aspiration occur without these reflexes Keep suction This is setup necessary to available as maintain needed patent airway Positions patients who have a Proper decreased positioning level of can consciousnes decreased risk for s on their aspiration.

was able to from injury. previous residuals indicates Maintain delayed upright position gastric for 30-40 mins. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: placement of NGT before A displaced feeding tube may erroneously deliver tube Check residuals feeding into the airway before feeding. environment by the use of the client will be by using padded side . Hold High if residuals amounts of are high. To minimize attaining After 2 hours of falls and safety Nursing Provide safety injury environment Intervention. gross and fine reduce injury motor through Short Term: coordination. emptying after feeding Facilitates gravitational flow of fluid or food. Assessment Diagnosis Planning Intervention Rationale Evaluation Risk for Long Term : Independent: Short Term injury After 2 days of Assess the To identify outcome was Nursing client’s risk for falls achieved. muscle The client the client will be strength. Intervention.

That can injury through contribute attaining safety Discuss of to environment by importance of occurrence using padded monitoring of injury side ails conditions to the relatives to identify risk for falls. . the risk for rails. NURSING CARE PLAN Patients Initials age/sex: Diagnosis: able to reduce padded side rails.