ASSESSMENT NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective Data Impaired physical Short Term Goal : Independent: Independent: Short Term Met
“kani ra may mobility related to After 1-2 hours of rendering 1) Present a safe environment: bed 1) These measures promote a safe, After 1-2 hours of
deperensya sa ako, weakness in the appropriate nursing rails up, bed in a down position, and secure environment and may reduce rendering
gahapon nag sugod right upper interventions the patient important items close by. the risk for falls. appropriate nursing
og binhod ni akong extremities will be able to performs 2) Provide foam or flotation mattress, 2) These types of equipment decrease interventions the
right na abaga”, as physical activity water or air mattress, or kinetic pressure on skin or tissues that can patient was able to
verbalized by pt. independently or with therapy bed, as necessary. damage circulation, potentiating the performs physical
assistive devices as needed. 3) Let the patient accomplish tasks at risk of tissue ischemia or breakdown activity
his or her own pace. Do not hurry the and decubitus formation. independently or
Long Term Goal : patient. Encourage independent 3) Healthcare providers and with assistive
Objective Data After 1 to 2 days of activity as able and safe. significant others are often in a hurry devices as needed.
 weakness and rendering appropriate 4) Provide the patient with rest and do more for patients than needed.
numbness of nursing interventions the periods in between activities.Thereby slowing the patient’s Long Term Met
right hand and patient will be regain or Consider energy-saving techniques. recovery and reducing his or her After 1 to 2 days of
arm. maintain mobility at the 5) Execute passive or active assistive confidence. rendering
 Limited Range highest possible level. ROM exercises to all extremities. 4) Rest periods are essential in appropriate nursing
of Motion conserving energy. The patient must interventions the
Collaborative: learn and accept his or her patient was able
1) Consult with physical or limitations. regain or maintain
occupational therapist as indicated. 5) Exercise enhances increased mobility at the
venous return, prevents stiffness, and highest possible
maintains muscle strength and level.
stamina. It also avoids contraction
deformation, which can build up
quickly and could hinder prosthesis
usage.

Collaborative:
1)To develop individual exercise/
mobility program.
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective Data: Impaired verbal Short Term Goal Independent: Independent: Short Term Met
communication related After 1 to 2 hours of 1) Learn patient needs 1) The healthcare After 1 to 2 hours of
to loss of facial control rendering nursing and pay attention to should set aside enough rendering nursing
and oral tone as interventions the patient nonverbal cues. time to attend to all of interventions the patient
Objective Data: evidence by slurring of will able to : 2) Place important the details of patient was able to :
 Stuttering or speech and facial  Establish a method objects within reach. care. Care measures  Establish a method
slurring words asymmetry to communicate 3) Provide an may take longer to to communicate
 Inability to use clearly to meet alternative means of complete in the clearly to meet
facial or body their needs communication for presence of a their needs
expressions  Participate in times when interpreters communication deficit.  Participate in
speech therapy or are not available (e.g., a 2) To maximize the speech therapy or
other therapy to phone contact who can patient’s sense of other therapy to
assist with interpret the patient’s independence. assist with
effective needs). 3) An alternative means effective
communication 4) Individualize of communication (e.g., communication
 Utilize devices and techniques using flashcards, symbol  Utilize devices and
equipment to breathing for relaxation boards, electronic equipment to
augment verbal of the vocal cords, rote messaging) can help the augment verbal
communication tasks (such as patient express ideas communication
counting), and singing and communicate
Long Term Goal or melodic intonation. needs. Long Term Met
After 1 to 2days of 5) Maintain a calm, 4) To assist aphasic After 1 to 2days of
rendering nursing unhurried manner. clients in relearning rendering nursing
interventions the patient Provide sufficient time speech. interventions the patient
will establish method of for the patient to 5) Individuals with was able to establish
communication in respond. expressive aphasia may method of
which need scan be 6) Involve family and talk more easily when communication in
expressed. significant others in the they are rested and which need scan be
 plan of care as much as relaxed and when they expressed
possible. are talking to one
7) Provide word-and- person at a time.
phrase cards, a writing 6) Enhances
pad, and pencil, or a participation and
picture board. Use eye commitment to the
blinks or finger plan.
movements for “yes” or 7) Supplemental
“no” responses. communication devices
are especially helpful
Collaborative: for intubated and
1)Refer to appropriate tracheal patients or
resources (e.g., speech those whose jaws are
therapist, group wired.
therapy,
individual/family and/or Collaborative:
psychiatric counseling). 1) Specialized services
may be required to meet
needs.

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Ineffective Cerebral Short term goal: Independent: Independent: Short Term Met:
“Oo, kani akong right Tissue Perfusion After 2-3 hours of 1. monitor vital 1. Irregularities in After 2-3 hours of
na kamot padulong diri related to infarcts in nursing intervention, signs noting: these are nursing intervention,
sa akong abaga, binhod the left thalamus and the patient will have hypertension or indications of the patient had
ni siya. Pero sa uban left lentiform nucleus adequate cerebral adequate cerebral
hypotension, problems/complicat
lawas nako wala na of the brain as perfusion as evidenced perfusion as evidenced
okay ra dayun”, as evidenced by reports by heart rate less than heart rate, ions of the brain by heart rate less than
verbalized by pt. of headache, blurring 120 beats per minute pupillary function. 120 beats per minute
of vision, and and blood pressure reaction and 2. Reduces arterial and blood pressure
weakness and 120/70 mm Hg respirations. pressure by 120/70 mm Hg
Objective Data: numbness of right immediately after 2. Position the promoting venous immediately after
 v/s: BP-120/70 hand and arm. position change, client with and drainage and may position change,
 weakness & normal skin color, dry normal skin color, dry
in neutral improve cerebral
numbness of skin, and absence of skin, and absence of
vertigo and syncope, position. circulation and vertigo and syncope,
the right upper 3. Promote active/ perfusion.
with return of heart with return of heart
extremities passive ROM 3. Exercise prevents
rate and blood pressure rate and blood pressure
to resting levels within exercise. venous stasis and to resting levels within
3 minute of position 4. Encourage further circulatory 3 minute of position
 Patellar
change. position compromise. change.
tendons reflex:
cannot fully Long term goal: changes within 4. Changes in position
grasp hand on Within 7 hours of the patient help adjust patient
Long Term Met:
the right side. rendering therapeutic when the to the upright After 7 hours of
nursing care, the patient is position. rendering therapeutic
patient will have: preparing to nursing care, the
 reports of  have move out of the patient :
slurring of improvements  Had
bed.
speech in terms of improvements
Collaborative:
movement. 1. To promote in terms of
 Have improve Collaborative: wellness. movement.
 cerebral tissue 1. Administer  Had improve
perfusion medication as cerebral tissue
ordered perfusion

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Risk for injury related Short term goal Independent: Independent: Short Term Met:
to altered sensory After 2 hours of nursing 1. Encourage to 1. To replace fluid After 2 hours of nursing
perception as intervention, the patient increase fluid loss and to intervention, the patient:
evidenced by vertigo will be able to: intake. prevent  Verbalize
Objective Data:  Verbalize 2. Monitor and dehydration. understanding of
Vital signs:
understanding record vital 2. To have individual
BP- 120/70
RR- of individual signs. baseline data. factors that
- Headache factors that 3. Provide a safety 3. It ensures contribute to
- Blurring of vision contribute to environment by safety and possibility of
- Dizziness possibility of keeping bed reduces risk for injury.
injury. rails up. falls.
4. Sit or lie down 4. Sudden Long Term Met:
Long term goal: right away movements can After 6 hours of nursing
After 6 hours of nursing when you feel trigger intervention the patient:
intervention the patient dizzy. Keep dizziness.
will be able to: your head as 5. To determine  Demonstrate
still as possible the causes of behaviors,
 Demonstrate lifestyle changes
 behaviors, and do not injury. to reduce risk
lifestyle changes change position factors and
to reduce risk quickly. Collaborative: protect self from
1. Help to control/
factors and 5. Assessed injury.
alleviate the
protect self from environmental
symptoms.
injury. factors that may
 had free from
lead to injury.
injury.
 Be free from
injury. Collaborative:
1. Facilitation of
oral
medication.

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Self-care deficit related Short term goal: Independent: Independent: Short Term Met:
to decreased strength in At the end of 1-2 hour 1. Encourage 1. An appropriate At the end of 1-2 hour
the right upper of nursing intervention independence level of of nursing intervention
extremities the client will be able but intervene assistive care the client was able to
Objective Data: to: verbalize the
- Patellar tendons when patient can prevent
importance of proper
reflex: cannot - Verbalize proper cannot perform. injury with hygienic practices like
fully grasp hand hygienic practices. 2. Provide patient activities bathing, proper hand
on the right side. with without causing washing, nail cutting,
- Can slowly move appropriate frustration. tooth brushing.
- Identify alternative utensils (e.g., 2. These items
fingers up and
action to perform drinking straw, increase Long Term Met
down on the right After 1-2 days of
Activity of Daily food guard, opportunities
hand. providing nursing
living. nonskid place for success. interventions, the
mat) to aid in 3. This ensures patient was able to
Long term goal self-feeding. easier dressing identify areas of
3. Encourage use and comfort. weakness and identify
Within 1-2 days of of clothing one 4. This enables his significant other as
effective nursing size larger. staff members his personal assistance.
intervention the client 4. Keep call light to have time to
will be able to identify
within reach assist with
individual area of
weakness or needs and and instruct transfer to
identify personal patient to call commode or
resources that can as early as toilet.
provide assistance. possible. 5. Stroke patients
5. Encourage experience
patient to use weakness in
the stronger their dominant
side (if side; therefore,
 appropriate) as it will be
best as possible necessary for
them to develop
Collaborative: muscle strength
1. Assured that
and
consistency of
coordination on
diet is
the stronger
appropriate for
side
patient’s ability
to chew and
swallow Collaborative:
1. Mechanical
problems may
prohibit the
patient from
eating.