Patient’s Name: Hospital No.

:
Age: Diagnosis:
Room No. Attending Physician:
Student/Placement: Date:

ASSESSMENT NSG. DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION

W/SCIENTIFIC CARE INTERVENTION
BASIS
S: “sukad naabot mi Impaired Verbal After 8 hours of INDEPENDENT After 8 hours of
diri, dili najud na siya Communication related nursing intervention, nursing intervention,
makatubag sa mga to aphasia as evidenced the patient will be able - Establish rapport - To build trust within the patient was able
gastorya sa iyaha sir by left extremity to; the patient and to the to;
biskan pa sa mga nurse weakness or paralysis watcher/family.
o doctor” as verbalized resulting in inability to ● maintain a ● maintained a
by the family member write or type. more stable - Speak in short, direct - Speaking in short and more stable
vital signs sentences. direct sentences while vital signs
O: presented communicating will presented
- Patient is unconscious SCIENTIFIC BASIS help the client and the
- Client’s inability to ● to participate in family members to ● have
comprehend or utter In this specific case, communication know what you will do participated in
words. the concomitant process (by and how will you do it. communication
- Complete weakness on presence of left nodding or process (by
the left side of the body. extremity weakness or moving of right - Display proper - Never speak loudly nodding or
- Inability to utter words paralysis indicates a extremities); speech etiquette when approaching the moving of right
- VS take as follows: neurological insult, ● utilize client when explaining extremities);
● BP: 140/90 often associated with resources and what you will do, ● utilized
mmHg damage to the motor devices to respect the client. resources and
● Temp: 36.9 regions of the brain, support devices to
degrees celsius which may be a result communication -Encourage family - Crucial for both the support
● RR: 21 of a stroke, traumatic process . participation patient and the family communication
● PR: 98 brain injury, or another to maneuver process .
● 02 sat: 96 neurological disorder. communication
- NVS : GCS score of 8 Left-sided extremity changes. GOAL PARTIALLY
impairment suggests a MET
 potential lesion in the - Provide safety and - To ensure that the
right hemisphere of the security as well as client will not be able
brain, given the comfort. to experience pain and
contralateral control of to not undermine the
motor functions in the healing process.
brain.
- Checking and - To have baseline data
The inability to write frequent monitoring of for the client to see if
NEEDS: or type, further the vital signs there will be elevation
exacerbated by left in terms of vital signs
PHYSIOLOGIC NEED extremity impairment, in order for the
underscores the healthcare team to
This client's condition practical consequences assess and give the
significantly impairs of aphasia in daily life. right medications.
their ability to meet Writing and typing are
basic physiological vital modes of - Regulate the IVF as - To know if there is a
requirements. Aphasia communication, and well as the medications significant impact in
has limited their verbal the loss of these being induced to the the health status of the
communication, while abilities can client. client as well as
left extremity weakness significantly impact a assuring that the client
or paralysis has hindered person's capacity to is able to get the
their capacity to write or convey their thoughts prescribed care.
type, both of which are and needs.
essential for expressing INDEPENDENT
their needs and seeking
help. To ensure their - Administer - To help alleviate the
well-being and safety, medication as client’s health status
immediate attention prescribed by the and to assure that there
must be given to physician is a great significance
addressing their physical in the treatment
health requirements. process
This may include
assessing their
nutritional needs,
mobility, and overall
health to prevent
complications related to
their physical
limitations.