ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired Physical Long term: 1. Assess the level of 1. Identifies both Goals were met.
“Nanginginig yung Mobility R/T Within 3 days of immobility on a 0–4 strengths and
kamay ko tuwing weakness and loss nursing intervention, scale, taking into weaknesses (for Long term:
humahawak ako ng the client will: Within 3 days of
of coordination as account your example, the
tabo” ● verbalize nursing intervention,
evidenced by the understanding of muscle mass and capacity to the client was able
Inability to control decrease of the situation and tone, joint mobility, ambulate with or to:
[RIGHT OR LEFT] muscle strength individual cardiovascular without ● verbalize
upper extremity and control treatment health, balance, assistance aids, understanding of
regimen and and endurance. the inability to the situation and
Numbness safety measures shift securely individual
● maintain position treatment
from bed to
Objective: of function and regimen and
VS skin integrity as wheelchair), and safety measures
● BP: 110/80 evidenced by it may also offer as avidenced by
● RR: 20 the absence of information about the statement,
● PR: 88 contractures the likelihood of “Kaya pala
● Temp: 36.8 recovery. nanghihina yung
Short term: kamay. Ngayon
t/c Cerebrovascular Within 8 hours of alam ko na kung
2. Aid in the 2. Muscle atrophy,
disease infarction nursing intervention, ano gagawin.”
on right MCA the client will: treatment of contractures, ● maintain position
territory ● demonstrate underlying pressure sores, of function and
techniques or illnesses that are constipation, skin integrity as
behaviors producing pain aspiration evidenced by the
that enable and/or malfunction. pneumonia, absence of
resumption thrombotic contractures
of activities
abnormalities,
● participate in Short term:
activities of and impaired Within 8 hours of
daily living immune system nursing intervention,
(ADLs) and function are a few the client will:
desired of the side effects ● demonstrate
activities of immobility that techniques or
behaviors
 is rarely limited to that enable
one body system. resumption of
activities as
evidenced by
3. To achieve
performance
3. Encourage the maximum of
patient to drink flexibility and recommende
enough water and performance. d exercises.
eat healthy foods. ● participate in
activities of
4. Schedule the 4. Optimizes the daily living
(ADLs) and
patient’s activities production of
desired
to include enough energy while activities
downtime for rest. fostering well-
being.
5. Set objectives for
the patient's
involvement in 5. By doing this, the
activities and patient's
position weariness will be
modifications with lessened.
the help of their
significant other
(SO).

6. Encourage them to
engage in self-care
activities such as 6. Encourages hope
work, hobbies, or for improvement
leisure time. and gives one a
the feeling of
control and
7. Promote the freedom.
client's or SO's
 participation in 7. Improves one's
decision-making. sense of
independence
8. Emphasize the and self-concept.
significance and
goals of regular 8. The patient's
exercise. functional
capability, ability
to carry out daily
tasks, and quality
of life are all
improved by
COLLABORATIVE regular exercise.
9. Cooperate along
with occupational COLLABORATIVE
or physical 9. To create a
therapists, physical personal fitness
medicine and mobility plan,
specialists, and choose the best
others to provide mobility
range-of-motion equipment, and
exercises, isotonic minimize the
muscle negative impacts
contractions, and problems of
assistive devices, immobility on the
and activities. patient.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for Altered Long term: 1. Evaluate the 1. Variations in Long term:
“Nanginginig yung Cerebral Tissue Within 3 days of patient’s consciousness Within 3 days of
kamay ko tuwing Perfusion R/T nursing intervention, consciousness and cognitive nursing intervention,
humahawak ako ng the client will: the client was able
suspected recent level, mental function are
tabo” ● display to:
cerebrovascular neurological health, speech, clinical signs of ● display
Inability to control disease infarction signs within and conduct. reduced cerebral neurological
[RIGHT OR LEFT] on right MCA client’s normal 2. Analyze the perfusion. signs within the
upper extremity territory range patient’s blood 2. Strokes and client’s normal
● demonstrate pressure. cerebrovascular range
Numbness behaviors and 3. Examine the spasms that can ● demonstrate
lifestyle behaviors and
laboratory tests, be triggered by
Objective: changes to lifestyle
VS improve as ordered by the either chronic or changes to
● BP: 110/80 circulation doctor. severe acute improve
● RR: 20 ● display no 4. Review arterial hypertension. circulation
● PR: 88 further blood gases or Inadequate ● display no
● Temp: 36.8 deterioration/re pulse oximetry. perfusion of the further
currence of 5. Maintain or brain is caused deterioration/re
t/c Cerebrovascular deficits currence of
restore fluid by low blood
disease infarction deficits
on right MCA Short term: equilibrium. pressure or
territory Within 8 hours of 6. Limit fluid intake severe Short term:
nursing intervention, and use diuretics hypotension. Within 8 hours of
Weakness the client will: if needed. 3. To recognize nursing intervention,
● verbalize 7. Maintain the ideal conditions that the client was able
understanding head of bed lower cerebral to:
of the ● verbalize
positioning (0, 15, perfusion or
condition, understanding
therapy or 30 degrees, for circumstances of the
regimen, side example) as that raise the risk condition,
effects of directed. of hemorrhage or therapy
medications, 8. Review any clotting. regimen, side
and when to relevant 4. Reduced brain effects of
contact a medications,
modifiable risk perfusion is
healthcare and when to
 provider factors, such as related to contact a
● demonstrate hypertension, hypoxia. healthcare
absence of smoking, 5. To increase provider as
signs of evidenced by,
nutrition, cardiac output
increased ICP “Sabi ng doctor
and vital signs exercise, and avoid ko wag ako
of: excessive alcohol hypovolemia- magkaka-kain
○ BP: 120/80 consumption, and related reduced ng matataba
○ RR: 12-20 illegal drug cerebral perfusion para di na
bpm usage. 6. To avoid cerebral maulit yung
○ PR: 60 - 100 9. Help the client edema and nangyari
bpm ngayoh.”
incorporate reduced cerebral
○ O2 sat: 95 - ● demonstrates
100 disease perfusion brought the absence of
management into on by signs of
daily activities. hypertension increased ICP
10. Stress the 7. To promote and vital signs
importance of cerebral of:
regular follow-up perfusion. ○ BP: 110/80
○ RR: 18 bpm
and laboratory 8. Information can
○ PR: 80 bpm
monitoring, as assist the patient ○ O2 sat: 98
necessary. in making
educated
decisions
regarding risk
factor
modification and,
when necessary,
lifestyle changes.
9. Independence is
encouraged, and
one's perception
of their capacity
to deal with
change and take
 care of their own
needs is
improved.
10. For the
purpose of
successful
disease
management and
potential
modifications to
the treatment
plan.
 REFERENCES
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
(Fifteenth). F.A. Davis Company.
Vera, M. B. (2022, March 18). 12 Stroke (Cerebrovascular Accident) Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/cerebrovascular-accident-stroke-nursing-care-plans/
Wagner, M. (2021, October 25). Impaired Physical Mobility Nursing Diagnosis & Care Plan. NurseTogether.
https://www.nursetogether.com/impaired-physical-mobility-nursing-diagnosis-care-plan/