WESLEYAN UNIVERSITY – PHILIPPINES

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NURSING CARE PLAN

NAME OF STUDENT: GROUP NO: LEVEL & BLOCK: DATE:

NAME OF PATIENT: Michael, 61-year-old MEDICAL DIAGNOSIS:

Assessment Nursing Diagnosis Nursing Goal Nursing Intervention Rationale Evaluation

Subjective Data: Actual Nursing Short Term Goal: Independent Nursing Interventions: Short Term Goal:
Diagnosis: To assist client to establish a means of communication to express needs, wants,
Not available After an hour of ideas, and questions. After an hour of
Impaired verbal nursing interventions: Establish rapport with patient, initiate This helps establish a trusting nursing interventions:
Objective Data: communication □ Patient will eye contact, address by preferred name, relationship with patient/family, □ Patient had
related to impairment verbalize or and meet the family members present; demonstrating caring about the patient verbalized or
Physical Exam of central nervous indicate an ask simple questions, smile, and engage as a person. indicated an
system as evidenced understanding of in brief social conversation if understanding of
Slurred speech by slurred speech the communication appropriate. the communication
(dysarthria) difficulty and plans Involve family/SO(s) in plan of care as This enhances participation and difficulty and plans
for ways of much as possible. commitment to communication with a for ways of
handling. loved one. handling.
□ Patient will □ Patient had
establish method of Keep communication simple, speaking Allays anxiety at having to process and established method
communication in in short sentences. Phrase questions to respond to large amount of information of communication
which needs can be be answered simply by yes or no. at one time. in which needs can
expressed. be expressed.
Speak slowly and clearly. Maintain a Forcing responses can result in Short term goals are
Long Term Goal: calm, unhurried manner. Provide frustration and may cause patient to met.
sufficient time for the client to respond. resort to “automatic” speech (garbled
After 2 days of nursing speech, obscenities). Long Term Goal:
interventions: Plan for and provide alternative methods Since the patient can understand
□ Patient will of communication. language but cannot speak very clearly. After 2 days of nursing
participate in  Establish hand or eye signals. interventions:
 therapeutic Use confrontation skills, when To clarify discrepancies between verbal □ Patient had
communication appropriate, within an established nurse- and nonverbal cues. participated in
(e.g., using silence, patient relationship. therapeutic
acceptance, communication
restating, reflecting, Collaborative Nursing Interventions: (e.g., using silence,
active- listening). Advise other healthcare providers of To minimize the patient’s frustration acceptance,
□ Patient will patient’s communication deficits. and promote understanding. restating, reflecting,
demonstrate active- listening).
congruent verbal □ Patient
and nonverbal Refer to appropriate resources. Patient and family may have multiple demonstrated
communication. needs (e.g., speech/language therapist, congruent verbal
□ Patient will be able further examinations and rehabilitation and nonverbal
to use resources services, support groups such as stroke communication.
appropriately. club). □ Patient was able to
Health Teaching: use resources
Teach patient and family the needed This enhances participation and appropriately.
techniques for communication, whether commitment to communication with a Long term goals are
it be speech or language techniques, or loved one. met.
alternate modes of communicating.
Encourage the family to involve the This reduces the stress of a difficult
patient in family activities using situation and promotes earlier return to
enhanced communication techniques. more normal life patterns.

Clinical Instructor: R.L.E. Coordinator: