NURSING CARE PLAN

Evalua
Date/Shift Assessment Need Nursing Diagnosis Objective of Care Nursing Intervention
tion
12/19/21 Subjective: P Risk for Ineffective After nursing Independent:
8:00AM “Dili na daw ni Cerebral Tissue intervention, the patient  Assess airway patency and
H
Mama malihok Perfusion related will: respiratory pattern.
iyang kamot Y to Cerebral Edema  maintain R: Neurologic deficits of a stroke
tapos nagbanhod as evidenced by usual/improved may include loss of gag reflex or
S
na wala na daw BP: 180/120 and level of cough reflex; thus, airway patency
siyay mafeel” as I body weakness, consciousness, and breathing pattern must be part
verbalized by secondary to cognition, and of the initial assessment.
O
the daughter. cerebrovascular motor/sensory  Frequently assess and monitor
L accident (stroke) function. neurological status. R: Assess
Objective:  will demonstrate trends in the level of consciousness
O
- BP: 180/120 Reference: stable vital signs (LOC), the potential for increased
- Body G Reference: Kozier and absence of ICP, and helps determine location,
weakness and Erb’s signs of extent, and progression of damage.
I
Fundamental of increased ICP. Prognosis depends on the
C Nursing 10th  ill display no neurologic condition of the patient.
Edition further  Monitor changes in blood
deterioration/re pressure, compare BP readings
N currence of in both arms. R: Hypertension is a
deficits. significant risk factor for stroke.
E
Fluctuation in blood pressure may
E occur because of cerebral injury in
D the vasomotor area of the brain.
 Position with head slightly
Circulation elevated and in a neutral
Maslow’s position. R: Reduces arterial
pressure by promoting venous
Hierarchy of drainage and may improve cerebral
Needs perfusion. During the acute phase
of stroke, maintain the head of the
bed less than 30 degrees.
 Maintain bedrest, provide a
quiet and relaxing environment,
 restrict visitors and activities.
Cluster nursing interventions
and provide rest periods
between care activities. Limit
duration of procedures. R:
Continuous stimulation or activity
can increase intracranial pressure
(ICP). Absolute rest and quiet may
be needed to prevent rebleeding.
 Prevent straining at stool,
holding breath, physical
exertion. R: Valsalva maneuver
increases ICP and potentiates the
risk of rebleeding.

Dependent:
 Administer medications as
indicated:
-
 Evalua
Date/Shift Assessment Need Nursing Diagnosis Objective of care Nursing Implementation
tion
12/12/21 Subjective: P Impaired Verbal After nursing Independent:
8:00 AM “Dili na niya Communication intervention, the  Provide alternative methods of
H
malihok ang related to loss of patient will: communication. R: A
katunga sa iyang Y oral muscle tone  indicate an communication board that has
lawas” as control by slurring understanding pictures of common needs and
S
verbalized by the of speech and of the phrases may help the patient. This
daughter. I facial asymmetry communication provides a method of communicating
secondary to problems. needs based on the individual
O
Objective: cerebrovascular  establish situation and underlying deficit.
- Slurring L accident (stroke) method of  Assess the patient for signs of
of speech communication depression. R: A patient with
O
- Facial Reference: Kozier in which needs aphasia may become depressed. The
asymmetr G and Erb’s can be inability to talk, communicate, and
y noted Fundamental of expressed. participate in a conversation can
I
on left Nursing 10th Edition often cause frustrations, anger, and
portion of C hopelessness. Make the atmosphere
the face conducive for communication and be
sensitive to the patient’s reactions
N and needs. The nurse can provide
E vital emotional support and
understanding to allay anxiety and
E frustration.
D  Talk directly to the patient,
speaking slowly and distinctly.
Speech Gain the patient’s attention when
Maslow’s speaking. Phrase questions to be
Hierarchy answered simply by yes or no.
Progress in complexity as the
of Needs
patient responds. R: Keep the
language of instruction consistent
and speak slowly. As speech
retraining progresses, advancing the
complexity of communication
stimulates the memory and further
enhances word and idea association.
Avoid completing the thoughts or
 sentences of the patient because it
can make the patient more frustrated
by not being able to speak.
 Speak in normal tones and avoid
talking too fast. Give the patient
ample time to respond. Avoid
pressing for a response. Use
gestures to enhance
comprehension. Respect the
patient’s pre-injury capabilities;
avoid “speaking down” to the
patient or making patronizing
remarks. R: Allow the patient
ample time to process instructions
and provide an environment for the
patient to feel esteemed because
intellectual abilities often remain
intact. Be patient with the patient.
 Discuss familiar topics (e.g.,
weather, family, hobbies, jobs).
R: Promotes meaningful
conversation and provides an
opportunity to practice skills.
Communicating during nursing
care activities can also provide a
form of social therapy to the patient.
 Encourage significant others to
continue communicating with the
patient like discussing family
happenings even if the patient
cannot respond appropriately. R:
Family members need to continue
talking to patients to reduce the
patient’s isolation, promote effective
communication, and maintain a
sense of connectedness with the
family.

Dependent:
 Consult and refer the patient to a
speech therapist. R: A speech
therapist can help assess the
communication needs of the patient,
identify specific deficits, and
recommend an overall method of
communication. Encourage the
patient to play an active part in
establishing goals so that language
intervention strategy is
individualized to their needs.
 Evalua
Date/Shift Assessment Need Nursing Diagnosis Objective of Care Nursing Intervention
tion
12/12/21 Subjective: P Impaired Physical After nursing Independent:
8:00AM “Dili na siya Mobility related to intervention, the patient  Assess the extent of impairment
S
makatarong og loss of balance and will: initially and functional ability.
lihok og dili siya Y coordination as  maintain/increa R: Identifies strengths and
katindog kay evidenced by se strength and deficiencies that may provide
C
matumba man” Stiffness on right function of information regarding recovery.
as verbalized by H upper and lower affected or  Observe the affected side for
the daughter. extremities compensatory color, edema, or other signs of
O
secondary to body part. compromised circulation. R:
Objective: L cerebrovascular  maintain Edematous tissue is more easily
- body weakness accident (stroke) optimal position traumatized and heals more slowly.
O
- uncoordinated of function as  Inspect skin regularly,
body movement G Reference: evidenced by particularly over bony
- stiffness on Nurse’s Pocket absence of prominences. Gently massage
I
right upper and Guide 14th edition contractures, any reddened areas and provide
lower extremities C foot drop. aids such as sheepskin pads as
 demonstrate necessary. R: Pressure points over
techniques/beha bony prominences are most at risk
N viors that enable for decreased perfusion. Circulatory
resumption of stimulation and padding help
E
activities. prevent skin breakdown and
E  maintain skin decubitus development.
integrity.  Change positions at least every 2
D
hrs. (supine, side-lying) and
Movement possibly more often if placed on
Maslow’s the affected side. R: Frequently
changing the position of the patient
Hierarchy can reduce the risk of tissue injury.
of Needs Place a pillow between the legs of
the patient before placing them in a
side-lying position.
 Place a pillow under the axilla to
abduct the arm. R: Helps prevent
adduction of the shoulder and
flexion of the elbow.
 Elevate arm and hand. R:
Promotes venous return and helps
prevent edema formation.
 Place hard hand-rolls in the
palm with fingers and thumb as
opposed. R: Hard hand rolls
decrease the stimulation of finger
flexion, maintaining finger and
thumb in a functional position.
 Place knee and hip in an
extended position. R: Maintains
functional position.
 Maintain leg in neutral position
with a trochanter roll. R:
Prevents external hip rotation.
 Assist patient in developing
sitting balance by raising the
head of the bed, assisting in
sitting on the edge of the bed,
having the patient use the strong
arm to support body weight,
and moving using the strong
leg.
 Assist in developing standing
balance by putting on flat
walking shoes. Support patient’s
lower back with hands while
positioning own knees outside
patient’s knees, assist in using
parallel bars.
 Position the patient and align his
extremities correctly. Use high-
top sneakers to prevent foot
drop, contracture, convoluted
foam, flotation, or pulsating
mattresses or sheepskin. R: These
are measures to prevent pressure
ulcers.
 Pad chair seat with foam or
 water-filled cushion, and assist
patient shift weight at frequent
intervals. R: To prevent pressure
on the coccyx and skin breakdown.
 Begin active or passive range-of-
motion (ROM) exercises on
admission to all extremities
(including splinted). Encourage
exercises such as
quadriceps/gluteal exercise,
squeezing a rubber ball, an
extension of fingers and
legs/feet. R: Active ROM
exercises maintain or improve
muscle strength, minimizes muscle
atrophy, promote circulation, and
helps prevent contractures. Passive
ROM exercises help maintain joint
flexibility.

Dependent:
 Incorporate minimal exercises
on a daily basis, ex: walking
around the house with
supervision
Vera (2021). Nurseslabs. 12 Stroke (Cerebrovascular Accident) Nursing Care Plans. Risk for Ineffective Cerebral Tissue Perfusion. Retrieved from
https://nurseslabs.com/cerebrovascular-accident-stroke-nursing-care-plans/, last December 2021

Vera (2021). Nurseslabs. 12 Stroke (Cerebrovascular Accident) Nursing Care Plans. Impaired Physical Mobility. Retrieved from
https://nurseslabs.com/cerebrovascular-accident-stroke-nursing-care-plans/2/, last December 2021

Vera (2021). Nurseslabs. 12 Stroke (Cerebrovascular Accident) Nursing Care Plans. Impaired Verbal Communication. Retrieved from
https://nurseslabs.com/cerebrovascular-accident-stroke-nursing-care-plans/3/, last December 2021