III.

Nursing Care Plan

Assessment Diagnosis Goal Intervention Evaluation
Objective: Ineffective Cerebral  The patient will be  Preventive: Assess factors related to  The patient was able
-Stuporous Tissue Perfusion able to maintain individual situation for decreased cerebral to improved level of
-GCS 3 related to Interruption usual/improved level perfusion and potential for increased ICP. consciousness as
-NIHSS Score 6 of blood flow: of consciousness,  Closely assess and monitor neurological evidenced by GCS
- Altered mental occlusive disorder, cognition, and status frequently and compare with baseline. score of 10.
status hemorrhage; cerebral motor/sensory  Monitor vital signs  The patient
-Behavioral vasospasm, cerebral function.  Evaluate pupils, noting size, shape, equality, demonstrated stable
changes edema  The patient will be light reactivity. vital signs and there
-Changes in motor As evidenced by able to demonstrate  Document changes in vision: reports of is no evidenced of
response Altered level of stable vital signs and blurred vision, alterations in visual field, depth further deterioration.
-Changes in consciousness. absence of signs of perception.
pupillary reactions increased ICP.  Position with head slightly elevated and in
-Difficult in  The patient will be neutral position.
swallowing able to display no  Maintain bedrest, provide quiet and relaxing
-Extremity further deterioration/ environment, restrict visitors and activities.
weakness or recurrence of deficits Cluster nursing interventions and provide rest
paralysis periods between care activities. Limit duration
-Speech of procedures.
abnormalities
 Curative :Administer medications as
Subjective: No
indicated: Alteplase (Activase), t-PA;
subjective Cues
Anticoagulants; Antiplatelet agents;
Antihypertensives; Neuroprotective agents;
Steriods; Peripheral Vasodilators

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Objective: Impaired Physical The patient will be  Preventive: Assess extent of impairment  The patient was able
-Unable to move Mobility related to able to initially and on a regular basis using NIHSS to increase strength
right upper and weakness of right maintain/increase scale 5a&b and 6a&b. and function on
lower extremities upper and lower strength and  Change positions at least every 2 hr (supine, affected area as
-limited range of extremities as function of affected side lying) and possibly more often if placed evidenced by
motion evidenced by inability or compensatory on affected side. cooperation during
-shows decreased to purposely move. body part.  Position in prone position once or twice a day rehabilitation course.
muscle streghth of The patient will be if patient can tolerate.  The patient was able
right side of the able to maintain  Observe affected side for color, edema, or to demonstrate
body optimal position of other signs of compromised circulation. techniques that
Subjective: “Hindi function as  Curative & Rehabilitative enable resumption of
ko maitaas ang evidenced by  Begin active or passive ROM to all activities
kamay ko” as absence of extremities (including splinted) on admission.  The patient was able
verbalized bt the contractures, foot Encourage exercises such as to maintain skin
patient drop. quadriceps/gluteal exercise, squeezing integrity.
The patient will be rubber ball, extension of fingers and legs/feet.
able to demonstrate  Assist patient with exercise and perform ROM
techniques/ exercises for both the affected and unaffected
behaviors that sides. Teach and encourage patient to use
enable resumption his unaffected side to exercise his affected
of activities. side.
The patient will be  Assist patient to develop sitting balance by
able to maintain skin raising head of bed, assist to sit on edge of
integrity. bed, having patient to use the strong arm to
support body weight and move using the
strong leg. Assist to develop standing balance

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 by putting flat walking shoes, support
patient’s lower back with hands while
positioning own knees outside patient’s
knees, assist in using parallel bars.
Objective: Self-Care Deficit  The patient will be  Preventive & Curative: Assess abilities and  The patient was
-Weakness on right related to able to demonstrate level of deficit (0–4 scale) for performing able to show positive
upper and lower neuromuscular techniques/lifestyle ADLs. attitude in
extremities impairment changes to meet  Avoid doing things for patient that patient can demonstrating
--limited range of decreased strength self-care needs. do for self, but provide assistance as techniques to meet
motion and endurance, loss  The patient will be necessary. his self care needs.
Subjective: “Hindi of muscle able to perform self-  Maintain a supportive, firm attitude. Allow  The patient was able
ko na kaya kumain control/coordination care activities within patient sufficient time to accomplish tasks. to slowly perform self
mag isa” as level of own ability. Don’t rush the patient. care activities such
verbalized by the  The patient will be  Provide self-help devices: extensions with as eating and
patient able to identify hooks for picking things up from the floor, combing.
personal/community toilet risers, long-handled brushes, drinking
resources that can straw, leg bag for catheter, shower chair.
provide assistance Encourage good grooming and makeup
as needed. habits.
 Rehabilitative: Refer patient to physical and
occupational therapist.
 Teach the patient to comb hair, dress, and
wash.
 Identify previous bowel habits and reestablish
normal regimen. Increase bulk in diet,
encourage fluid intake, increased activity.

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