NURSING CARE PLAN
SORIANO, Angelica Joan M.
NCM 114
THE OLDER ADULT WITH A CEREBROVASCULAR ACCIDENT:
CONVALESCENE PERIOD
Scenario 1: NURSING DIAGNOSIS: (1) Self-Care Deficits related to sensory or
motor impairment, visual deficits, fatigue, aphasia; (2) Activity Intolerance related to
depression, poor motivation, prolonged immobility and fatigue.
GOAL
The patient will be able to determine the
safe limits of trying to be independent
versus asking for assistance when
necessary.
The patient will maintain muscle strength
and joint range of motion (ROM).
NURSING ACTIONS
 Guide the patient in accepting the
needed amount of dependence.
 Present positive reinforcement for
all activities attempted; note
partial achievements.
 Render supervision for each
activity until the patient exhibits
the skill effectively and is secured
in independent care; reevaluate
regularly to be certain that the
patient is keeping the skill level
and remains safe in the
environment.
 Implement measures to promote
independence, but intervene when
the patient cannot function.
 Boost maximum independence.
 Apply regular routines, and allow
adequate time for the patient to
complete task.
 Educate family and significant
others to promote autonomy and
to intervene if the patient becomes
tired, not capable of carrying out
task, or become extremely
aggravated.
 Inform family members to allow
the patient perform self-care
measures as much as possible.
 Promote independence, but
intervene when the patient is not
able to carry out self-care
activities.
 Consider or use energy-
conservation techniques.
 Assess patient’s tolerance to the
exercise regimen and note for any
physiologic changes.

The patient will engage in diversional
activities and relates the absence of
boredom.
 Perform a range of motion
exercises on each extremity.
 Avoid isometric exercises if the
patient has a history of heart
disease.
 Start with passive exercises,
moving the joints through the
motions of extension, flexion,
abduction, and adduction.
 Progress to active-assisted
exercises in which you support
the joints while the patient
contracts a certain muscle group,
moves the extremity at a slow
pace, and then relaxes the muscle
group.
 Discontinue the exercise if the
patient experiences shortness of
breath, lightheadedness, dizziness,
syncope, or severe pain. Notify
physician accordingly.
 Discontinue any exercise once the
patient complains of muscular or
skeletal pain. Refer to a physical
therapist about any modifications.
 Assess the activity tolerance of
the patient.
 Assess for evidence of the patient
having an interest in something to
read or do, daytime napping, and
expressed inability to do leisure
activities due to depression, poor
motivation, prolonged immobility,
and fatigue.
 Collect a database by evaluating
the patient’s usual support
systems and relationship patterns
with significant others.
 Ask the patient and significant
other about the patient’s interests.
 Allow discussion of previous
activities or reminiscence.
 Encourage significant others to
visit within limits of the patient’s
endurance and to involve the
patient in activities that are of
interest to him or her.
 Initiate activities that demand
little concentration and progress
to more complex tasks as the

The patient progressively increases
independence in activities of daily living.
Patient will demonstrate optimal
performance of activities of daily living.
patient’s condition permits.

 Provide low-level activities to the
patient’s tolerance.
 Personalize the patient’s
environment with favorite items
and images of significant others.
 Increase the patient’s participation
in self-care.
 encourage the use of appropriate
diversional activities such as
puzzle, model kits, handicrafts,
and computerized games and
activities.
 Recommend that the patient’s
significant other recreational
devices, crafts, and personal
grooming from home.
 Allow the patient to view outside
activities by assisting him or her
in a chair near a window, provide
the patient an opportunity to sit in
a solarium so that he or she can
visit other patients, and if feasible,
bring the patient outside for a
short period.
 Evaluate the need for
occupational therapy, psychiatric
nurse, social services, and
spiritual services for consultation.
 Assess patient’s independence-
dependence in each of the
activities of daily living.
 Assess cognition and emotional
status.
 Consult with the physical
therapist (PT).
 Develop plans for exercises,
transfer techniques, and mobility
aids.
 Consult with the occupational
therapist
 Assess the self-care limitations of
the patient.
 Make sure that the patient
receives the prescribed pain
management.
 Initiate an efficient exercise
regimen that will promote
endurance, strength, and
 improvement of muscle groups
necessary for the particular
activity deficit of the patient.
 Refer the patient to occupational
therapy if indicated, and make use
of assistive devices and
dressing/grooming aids as needed.
 Instruct significant others how to
assist the patient during self-care
activities.
 Refer to care management/social
services department of the
hospital as needed.

Scenario 2: NURSING DIAGNOSIS: Impaired Physical Mobility related to

sensory and motor function.

GOAL NURSING ACTIONS

 Check for functional level of
mobility.
 Evaluate patient’s ability to
perform Activities of Daily Living
efficiently and safely on a daily
basis.
 Assess for impediments to
mobility
 Assess the strength to perform
ROM to all joints.
 Assess input and output record
and nutritional pattern.
 Monitor nutritional needs as they
relate to immobility.
The patient performs physical activity
 Evaluate the need for assistive
independently or within limits of disease.
devices.
 Assess presence or degree of
exercise-related pain and changes
in joint mobility.
 Assess the safety of the
environment.
 Assess the emotional response to
the disability or limitation.
 Consider the need for home
assistance (e.g., physical therapy,
visiting nurse).
 Assess the patient’s or caregiver’s
understanding of immobility and
its implications.
 Assist patient for muscle exercises
The patient’s independent mobility is as able or when allowed out of
progressively increasing. bed; execute abdominal-

The patient is free from complications of
immobility,
tightening exercises and knee
bends; hop on foot; stand on toes.
 Present a safe environment: bed
rails up, bed in a down position,
important items close by.
 Establish measures to prevent skin
breakdown and thrombophlebitis
from prolonged immobility
 Execute passive or active assistive
ROM exercises to all extremities.
 Promote and facilitate early
ambulation when possible. Aid
with each initial change: dangling
legs, sitting in chair, ambulation.
 Show the use of mobility devices,
such as the following: trapeze,
crutches, or walkers.
 Help out with transfer methods by
using a fitting assistance of
persons or devices when
transferring patients to bed, chair,
or stretcher.
 Let the patient accomplish tasks at
his or her own pace. Do not hurry
the patient. Encourage
independent activity as able and
safe.
 Give positive reinforcement
during activity. Patients may be
unwilling to move or initiate new
activity because of fear of falling.
 Provide the patient of rest periods
in between activities. Consider
energy-saving techniques.
 Give medications as appropriate.
 Help patient in accepting
limitations.
 Encourage resistance-training
exercises using light weights
when suitable.
 Help patient develop sitting
balance and standing balance.
 Present suggestions for nutritional
intake for adequate energy
resources and metabolic
requirements.
 Encourage a diet high in fiber and
liquid intake of 2000 to 3000 ml
per day unless contraindicated.
 Offer diversional activities.
 Observe emotional or behavioral
reactions to immobility.
 Explain to the patient the need to
call for help, such as call bell and
special sensitive call light.
 Set goals with patient or
significant other for cooperation
in activities or exercise and
position changes.
 Reinforce principles of
progressive exercise, emphasizing
that joints are to be exercised to
the point of pain, not beyond.
 Teach patient or family in
maintaining home atmosphere
hazard-free and safe.
 Give explanation about
progressive activity to patient.

Scenario 3: NURSING DIAGNOSIS: (1) Altered Role Performance related to

loss of body function, physical changes, role changes; (2) Altered Family Process
related to changes in function, dependency on family for caregiving, ineffective
coping

GOAL NURSING ACTIONS

The patient expresses acceptance of
altered lifestyle and functions.
 Assess for the presence of
defining characteristics.
 Observe for causes of ineffective
coping such as poor self-concept,
grief, lack of problem-solving
skills, lack of support, or recent
change in life situation.
 Identify specific stressors.
 Observe for strengths such as the
ability to relate the facts and to
acknowledge the source of
stressors.
 Determine the patient’s
understanding of the stressful
situation.
 Analyze past use of coping
mechanisms including decision-
making and problem-solving.
 Monitor risk of harming self or
others and intervene
appropriately.
 Evaluate resources and support
systems available to the patient.
 Assess for suicidal tendencies.
Refer for mental health care

The patient develops or maintains
satisfying interactions with family.
The patient will develop realistic goals
for independence and participate in self-
care.
immediately if indicated.
 Assess for intergenerational
family problems that can
overwhelm coping abilities.
 Set a working relationship with
the patient through continuity of
care.
 Assist patient set realistic goals
and identify personal skills and
knowledge.
 Provide chances to express
concerns, fears, feeling, and
expectations.
 Use empathetic communication.
 Convey feelings of acceptance
and understanding. Avoid false
reassurances.
 Encourage patient to make
choices and participate in
planning of care and scheduled
activities.
 Encourage the patient to
recognize his or her own strengths
and abilities.
 Consider mental and physical
activities within the patient’s
ability (e.g., reading, television,
outings, movies, radio, crafts,
exercise, sports, games, dinners
out, and social gatherings).
 Assist patients with accurately
evaluating the situation and their
own accomplishments.
 Provide information the patient
wants and needs. Do not give
more than the patient can handle.
 Assess the response of the patient
to the care plan for recovery.
 Refrain from minimizing the
patient’s expressed feelings of
depression
 Allow expressions of emotions,
but facilitate an environment full
of understanding, support, and
realistic hope for a positive role
change
 Provide consistency in conveying
expectations of eventual
independence.
 Encourage the patient to be as

The patient will be able to define the
characteristics of behavioral and
physiological responses related to stress
and provide clues to the level of coping
difficulty.
REFERENCES
1. Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders
Elsevier.
independent as possible within
limitations of endurance, therapy,
and pain.
 Alert the patient to areas of
excessive dependence, and
involve him or her in
collaborative goal setting.
 Provide assistive devices if
indicated.
 Provide positive reinforcement
when the patient meets or
advances toward goals.
 Assess for the presence of
defining characteristics.
 Assess for the influence of
cultural beliefs, norms, and values
on the patient’s perceptions of
effective coping.
 Observe for causes of ineffective
coping such as poor self-concept,
grief, lack of problem-solving
skills, lack of support, or recent
change in life situation.
 Assess for intergenerational
family problems that can
overwhelm coping abilities.
 Identify specific stressors.
 Observe for strengths such as the
ability to relate the facts and to
acknowledge the source of
stressors.
 Determine the patient’s
understanding of the stressful
situation.
 Analyze past use of coping
mechanisms including decision-
making and problem-solving.
 Monitor risk of harming self or
others and intervene
appropriately.
 Evaluate resources and support
systems available to the patient.
 Assess for suicidal tendencies.
Refer for mental health care
immediately if indicated.
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