BULACAN STATE UNIVERSITY COLLEGE OF NURSING City of Malolos Brgy.

Gugo, Calumpit Purok 6 NURSING CARE PLAN 1st sem SY- 2011-2012 Name of Student: Roman, Anna Krizia A. Section: BSN 4F Patient SS 88 y/o hypertension and mild cva ASSESSMENT Subjective: Naliliyo ako at hindi ko maigalaw yung kalahati ng katawan ko kanina, as verbalized by the client Objective: Pale and weak in appearance Numbness of left body Dizziness V/S taken as follows: BP 150/80 mmhg T - 37.5 C RR 22 cpm DIAGNOSIS Ineffective tissue perfusion related to interruption of blood flow secondary to mild CVA PLANNING IMPLEMENTATION RATIONALE EVALUATION Goal met: Provides baseline data for nursing care. Radical changes may indicate that the condition got worse. To reduce stress the patient was able to demonstrate behaviour/lifestyle changes to improve circulation

After 2 hours of nursing Independent intervention the patient will be able to: Assess general health status. Demonstrate behaviour/lifestyle Monitored and changes to improve recorded vital signs. circulation Provided calm, restful surroundings, minimize environmental activity/noise.

Stress importance of accomplishing daily

Alternating rest and activity increases

PR 106 bpm

rest periods.

tolerance to activity progression

Elevated head Promotes venous RETURN of the bed 30-40 degrees. Collaborative: Administer medication with caution and as prescribed by the physician like vasodilators.