Patient Name: Secuya, Juanito

Room: 239
Attending Physicians: Dr. Jefho, Dr. Lim, Dr. Madayag
Chief Complaint: Right-sided weakness

Date/ Cues Needs Nursing Diagnosis Pt. Outcome Planning/ Intervention Implementation Evaluation
Time

S Subjective cues: H Impared physical At the end of my 8 hours a) Change the position of the pt 09/09/2020 3:00 pm
E - Pt E shift, the patient/watcher every 2 hrs.
mobility related to
P verbali A will be able to: R: to provide comfort and GOAL MET
T. zed L hemiparesis as prevent bed sores
“nurse T evidenced by - know general b) Provide right side motions at In my 8 hours shift, the patient/watcher
9, dili ko H knowledge on least 4 times was able to:
kabako right-sided how to manage R: to maintain joint mobility
2 d ug M weakness. pt’s condition and promote good circulation. ● Know general knowledge about
0 tarong” A c) Establish rapport with the managing the pt’s condition
2 - Pt feels N - Be comfortable in patient in order to gain ● Receive comfort in every
0 numbi A every position cooperation and trust position
Hemiparesis
ng in G change d) Monitor the vital signs ● Urinate and defecate without
occurs when one
7:00a the E e) Provide pillow support moving excessively
side of the body is
m right M - Urinate or f) Give diuretics to pt. as ordered
weakened, and it
side of E defecate with by the physician Mary Justine Africa, STN
typically impacts
the N minimal
your limbs and
body T movement
facial muscles
(Hoffman, 2017).
Objective cues:
-VS
https://www.saeb
Bp - 140/100
o.com/blog/treati
ng-hemiplegia-
-Pt unable to raise
hemiparesis-
right arm and leg
stroke/
- Facial droop on
the right side of
the face
- Initial movement
score of 2 with the
scale of 1-4 being:
1 - no movement
at all
2 - with little
movement but
with numbness
3 -with movement
but with little
numbness
4 - with significant
movement with
no numbness