NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Impaired During 4 hours After 4hours

Patient report to comfort and Patient will report a Nursing Management: (5) – To determine the She verbalized being
headache, related to decrease headache - Note for the location, nursing care to be relieved of pain 2/10
dysarthria, and left headache. by pain less 2 on 1- scale, intensity and onset given to the patient. scale. And there is no
sided weakness.  10 scale. of pain. non-verbal indicators
impaired – To minimize stimulus of pain.
physical Patient will performs - Maintain a calm and that could aggravate
mobility related Physical therapy of quite environment. the condition of the She need to stay in
Objective: patient. hospital to perform
to left sided left sided.
weakness. - Reviewed functional physical therapy
– Pain scale:6/10 The patient will be abilities and reasons for – To help relieve of pain.
– facial grimace. able to use impairment.
impaired motor
– Identifying the She able to use
function of alternative methods
– Decrease in of communication. - Encouraged patient to do specific cause guides
alternative methods of
muscles of communication.
movement And assess tongue physical activities such as design of optimal
speech related And tongue movement
– impaired movement . exercise. treatment plan.
ability to hold to dysarthria. and strength was also
adequate.
objects. – This is to enable the
– have difficulty - Assess extent of patient to regain
of speech. dysfunction of muscular muscle strength.
impairment of speech.
 - Have patient produce
simple sounds (Him,Shh)
Medical Mgt (5):
Paracetamol 10mg IV
Normal saline0.9% IV
– because motor
Al Riyada College for Health Sciences
Jamjoom Center, Jeddah, KSA
– Helps determine area
and degree of brain
involvement and
difficulty patient has
with any or all steps
of the
communication
process.
components of
speech (tongue, lip
movement, breath
control) can affect
articulation.
 Name of Student: Rawan Musa khateeb Date Submitted: ______________ MR: _________

Name of Hospital: _______________________________ Area: ______________ Room#:_____________

Patient Data

Name of Patient: ****** Age: 50years Gender: Female

Nationality: __________________________ Marital Status: ________________________

DOA (Date of Admission): ______________

Medical Diagnosis: ________________________________________________________

Reason for admission: headach,dysarthria,and left sided weakness.

CASE STUDY CONFIRMATION BY THE CI: __________________________ SIGN/DATE: ________________

References

Headaches: Causes, types, and treatment. (n.d.). Retrieved from https://www.medicalnewstoday.com/articles/73936#types

Dysarthria & Speech: Symptoms, Causes, Treatments. (n.d.). Retrieved from https://my.clevelandclinic.org/health/diseases/17653-dysarthria

Hemiparesis. (n.d.). Retrieved from https://www.stroke.org/en/about-stroke/effects-of-stroke/physical-effects-of-stroke/physical-

impact/hemiparesis