patient's profile

Name: Mr. W
Age: 78 years old
Address: New England
Diagnosis: right
cerebrovascular accident
(CVA) with left hemiparesis
 Assessment
Subjective:
"I want to eat by myself but I
cannot." as verbalized by the client.
 Assessment
Objectives
Unable to perform Activity of daily living such as eating, brushing
teeth, and combing hair.
hemiplegia
hemiparesis
Vital Signs:
90%
130/100mmHg

13cpm

96bpm
 Diagnosis

Self - care deficit related to

neuromuscular impairment as
evidenced by hemiparesis.
 Planning
SHORT TERM: AFTER 8 HOURS OF NURSING INTERVENTION,
THE CLIENT WILL DEMONSTRATE TECHNIQUES AND LIFESTYLE
CHANGES TO MEET SELF - CARE NEEDS AS EVIDENCE BY
TRYING TO FEED HIMSELF.

LONG TERM: AFTER 6 MONTHS OF NURSING INTERVENTION,

THE CLIENT WILL PERFORM SELF - CARE ACTIVITIES WITHIN
LEVEL OF OWN ABILITY AS EVIDENCE BY TAKING A BATH,
EATING, BRUSHING TEETH, DOING ADL'S ON HIS OWN.
 Independent

Nursing Intervention
Intervention
Keep the environment
organized and uncluttered.

Rationale
Because patient with cognitive
impairment is easily
distracted.
 Intervention
To assist the client in dressing
aids, place the clothing on the
affected side.

Rationale
In order in which the garments are
to be put on.
 Intervention
Allow the use of large mirror
when dressing.

Rationale
to promote the client's awareness
of what he or she putting in the
affected area.
 Intervention

Provide nonskid mats when

eating.

Rationale
to stabilize the plate.
 Intervention
Place plate guards when the client
is eating.

Rationale
To prevent food from being
pushed off plate.
 Intervention

Support and encourage the

patient in performing the
activities.

Rationale
To prevent the patient from
becoming overly fatigue and
discourage.
Collaborative Nursing

Intervention
 Intervention
Collaborate with the
rehabilitation professionals
for assistive devices and
mobility aids such as cranes
or crutches.
Rationale
To enhance client's capacity and
promote independence.
Project 4 name

Client name:
Presentations are tools that can be used as
demonstrations, lectures, speeches, reports, and
more. It is mostly presented before an audience.
 Evaluation
SHORT TERM: AFTER 8 HOURS OF NURSING INTERVENTION,
THE CLIENT DEMONSTRATED TECHNIQUES AND LIFESTYLE
CHANGES TO MEET SELF - CARE NEEDS AS EVIDENCED BY
TRYING TO FEED HIMSELF.

LONG TERM: AFTER 6 MONTHS OF NURSING INTERVENTION,

THE CLIENT PERFORMED SELF - CARE ACTIVITIES WITHIN
LEVEL OF OWN ABILITY AS EVIDENCE BY TAKING A BATH,
EATING, BRUSHING TEETH, DOING ADL'S ON HIS OWN.