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Nursing Scientific Nursing Expected

Assessment Objective Rationale


Diagnosis Explanation Interventions Outcome
S=Ø Language deficit The patient’s Short Term: >Establish rapport >To gain trust and Short term:
O= The patient (aphasia) related condition After 5° of cooperation of the The patient
manifested the to brain surgery happens due to Nursing >Monitor and patient shall have
following: (decrease surgical Intervention, record vital signs >To obtain baseline demonstrated
>Unable to circulation to the operation of the the patient will data and to note behavior on
speak brain and brain in which the be able to significant changes in how to
dominant damage to the left side of the demonstrate the vital signs of the improve
languages left side of the brain is being behavior on >Assess patient’s patient communication
>Speaks or brain responsible damaged and how to general condition >To assess for little by little as
verbalizes with for this left side of improve improvements/changes evidenced by
difficulty speech/language) the brain is communication in the patient’s compliance
>Has difficulty responsible for little by little as >Keep condition with the
in expressing the motor evidence by communication >In order for the treatment
thoughts functions of the compliance simple, using all patient to easily regimen and
verbally body specifically with the modes for understand and health
>has difficulty speech or treatment accessing communicate verbally teachings
in language regimen and information: visual, and to express being given
comprehending resulting to health auditory and thoughts or feelings
and Aphasia. teachings kinesthetic and needs without Long Term:
maintaining the Aphasia is a being given. >Maintain eye much effort to exert The patient
usual disorder that contact with the >To enhance patient’s shall have
communication results from Long Term: patient when understanding of what established
pattern damage to the After 4 days of speaking is being communicated method of
>Unable or has parts of the brain Nursing and in order for them communication
difficulty in use that contain Intervention, to easily comply with in which needs
of facial or language. the patient will the interventions being are being
body Aphasia causes be able to >Use confrontation given expressed as
expressions problems with establish skills, when >To clarify evidenced by
any or all of the method of appropriate, within discrepancies between patient
=The patient following: communication an established verbal and non-verbal demonstrated
may manifest speaking, in which needs nurse-client cues behavior in
the following: listening, reading, can be relationship constructing
>Stuttering and writing. expressed as >Encourage simple
>Disorientation Muscles of the evidence by patient to try to say sentences
in three lips and tongue constructing words or simple without
spheres of may be weaker simple sentences little by >To enhance exerting much
time, space, (dysarthria) or sentences little communication skills effort to speak.
person less coordinated which does not and to regain his
>Inappropriate (apraxia).Speech require much normal verbal
verbalization may not be clear. effort to speak. communication
>Absence of Breathing
eye contact muscles may be
>Willful refusal weaker, affecting
to speak the patient's
ability to speak
loudly enough to
be heard in
conversation.
Assessment Nursing Scientific Objective Nursing Rationale Expected
Diagnosis Explanation Interventions Outcome
S=Ø Ineffective The condition of Short term: >Establish rapport >To gain trust and Short Term:
cerebral tissue the patient is After 5° of cooperation of the The patient
O= The patient perfusion related brought about by Nursing patient shall have
manifested the to impaired many factors Intervention, demonstrated
following: transport of the such as lifestyle the patient will >Monitor and >To obtain baseline behavior on
>Numbness on O₂ across (smoking, alcohol demonstrate record vital signs data how to
the left alveolar/ or intake), age, behavior on manage his
extremities capillary nature of work how to >Assess patient’s >To identify underlying condition,
>dizziness membrane and his health manage his general condition factors that contribute therapy
>headache secondary to history (Diabetes condition, to his condition and to regimen, side-
>increased Diabetes Mellitus Mellitus and therapy note if there are effects of the
blood pressure hypertension). regimen, side- improvements/ medication
>altered Cigarette, which effects of the changes in the and when to
mental status; contains nicotine, medication patient’s condition contact health
Speech and alcohol and when to care
abnormalities intake cause contact health >To note the severity professional as
>difficulty of constriction of the care >Determine the of the patient’s evidenced by
swallowing blood vessels professional as duration of the condition and to also compliance
which impaired evidence by problem/frequency assess for the with the
= The patient blood flow to the compliance of recurrence, interventions medication
may manifest different parts of with the precipitating or appropriate for the and health
the following: the body medication aggravating factors patients condition teachings
>Restlessness particularly in the and health being given.
>Confusion brain. Also teachings >To obtain reliable,
>Lethargy because of his being given. >Determine objective way of Long Term:
>Seizure lifestyle, he presence of visual, recording the The patient
activity developed Long Term: sensory/motor conscious state of a shall have
>Pupillary hypertension that After 4 days of changes, person demonstrated
changes has lead as well Nursing headache, lifestyle
>Decreased in increased Intervention, dizziness, altered modification as
reaction to light intracranial the patient will mental status evidenced by
pressure. demonstrate (Glassgow Coma >To promote cessation of
Another factor, lifestyle Scale) circulation or venous smoking,
which is modification to >Elevate head of drainage and decrease dietary
Diabetes, causes improve bead, and maintain intracranial pressure changes and
viscosity of the circulation as head/neck in exercise.
blood. evidence by midline or neutral >To improve the
Vasoconstriction cessation of position patient’s condition
and viscosity of smoking,
the blood of the dietary
patient have changes and >Administer >To saturate
impaired the exercise. medications as circulating hemoglobin
Oxygen supply to directed and increase the
the brain, and effectiveness of blood
because of too >Administer that is reaching the
much pressure oxygen as needed ischemic tissue
the blood has to
exert going to the >To promote wellness
brain, the and educate the client
cerebral arteries about the factors that
are forced to could aggravate his
dilate resulting to condition if he
increase intra continuously smoke
cranial pressure >Encourage
and hyperfusion. patient to quit >In order for the
smoking as this is patient to prevent
one of the further complication
contributing factors such as chest pain and
to his condition high blood pressure

>Instruct the
patient to avoid
fatty, greasy highly
seasoned food
Assessment Nursing Scientific Objectives Interventions Rationale Evaluation
Diagnosis Explanation

S> Ø Risk for injury r/t One of the Short term: > Establish rapport > To gain trust of the patient and
O> received to generalized complications After 4 hrs. of > Monitor and patient/SO his SO shall
patient on bed weakness and that may arise nursing recoded vital signs > To obtain baseline have
conscious, limited ROM after a CVA is the intervention > Assess patient’s data participated in
coherent numbness, the patient and condition prevention
> with intact paralysis, or his SO will > Note changes in > To assess measures of
suture over the weakening of participate in color, texture & causative/contributing possible
head either the half of prevention turgor factors injuries
> appears the body or the measures of > Identify > To assess extent of
weak whole body this possible underlying involvement/injury
>Unable to depends on the injuries condition/pathology > To assess
move left brain that was involved causative/contributing the patient
extremities been damaged. Long Term: > Note presence of factors shall have
After 4 days of uncompromised displayed
nursing vision, hearing or > To determine impact management
intervention, speech of condition of simple
the patient will > Provide wound ADL’s with the
display care apt support of
management > To assist client w/ the SO
of simple correcting/ minimizing
ADL’s with the condition & to promote
apt support of optimal healing
the SO > modify client’s > to prevent fatigue
activity > To promote wellness
> Encourage client
to verbalize
feelings esp. pain
> free clients > to minimize chances
bedside from of acquiring injury
articles that may
promote injury > To involve patients
> Instruct the SO family in his care and
on how to assist to maximize clients
their patient in willingness
doing his ADL’s > for continuity of care

>refer client to
rehab to regain
strength

Assessment Nursing Scientific Objectives Interventions Rationale Expected


Diagnosis Explanation Outcome
S> Ø Activity A patient who is Short Term > establish rapport > to gain patient’s trust Short-Term
Intolerance r/t always on bed and cooperation The pt’s. SO
O> the pt may decreased rest may feel a After 2-3 hours shall
manifest muscle strength decreased in of NI patient’s > monitor and > to serve as baseline verbalized
muscle strength SO will record VS data understanding
> decreased in due to lack of verbalize of methods
muscle movement. The understanding > assess patient’s > to provide and
strength muscles may feel of methods condition appropriate techniques to
stiff and weak and interventions increase pt.
> generalized because they are techniques to immediately muscle
weakness not exercised increase strength
> fatigue and used. Lack patient’s > provide massage
of movement muscle on extremities > for proper blood
> muscle may also cause strength. circulation Long-Term
atrophy muscle atrophy, > provide patient
wherein there is Long Term enough time to Patient’s shall
also a decrease perform activities > to minimize patient’s demonstrated
in muscle After 2-3 days anxiety when doing activity
strength. When of NI, patient tasks tolerance is
muscle strength will > increase activity increased AEB
is decreased, the demonstrate level gradually performing
person may show activity self-care.
intolerance in tolerance AEB > provide quiet > to avoid overexertion
performing, even doing self-care environment
simple, activities. with minimal suitable for rest
The person may support. > to regain strength
easily feel fatigue
even in just doing
easy tasks.