PAJARILLAGA, PAULA BIANCA B.

BSN 3B/B2
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION
Nursing Care Plan RATIONALE EVALUATION
Subjective data: Impaired After 5 hours of Independent: After 5 hours of nursing
“Hindi ako makagalaw physical mobility nursing interventions  Assess extent of  Identifies strengths interventions the patient
katulad ng dati, di ko related to the patient will impairment and deficiencies that demonstrated
magalaw yung kanang paralysis on the demonstrate initially and on a may provide understanding of the
parte ng katawan ko.” right side of the understanding of the regular basis. information management as
body. management as Classify regarding recovery. evidenced by
Objective data: evidenced by according to 0–4 Assists in choice of verbalizing
(+) Numbness on the verbalizing scale. interventions understanding to care
right side of the body understanding to care because different plan and performing
(+) Facial drooping plan and performing techniques are used some exercises to
(+) Dysarthria some exercises to for flaccid and strengthen the function
(+) Ataxia strengthen the spastic paralysis. of affected body part.
function of affected
Vital signs as follows: body part.  Inspect skin  Pressure points over  Goal met
regularly, bony prominences
 BP: 120/80 mm Hg particularly over are most at risk for
 PR: 80 bpm bony decreased perfusion.
 RR: 18 cpm prominences. Circulatory
Gently massage stimulation and
Laboratory findings: any reddened padding help
areas and provide prevent skin
 MRI: showed an aids such as breakdown and
acute 1.7-cm infarct sheepskin pads as decubitus
of the left necessary. development.
periventricular
white matter and  Change positions
posterior left basal at least every 2
ganglia hours (supine,  Reduces risk of
side lying) and tissue injury.
possibly more Affected side has
often if placed on poorer circulation
affected side. and reduced
sensation and is
PAJARILLAGA, PAULA BIANCA B.
BSN 3B/B2
more predisposed to
 Prop extremities skin breakdown.
in functional
position; use  Prevents
footboard during contractures and
the period of footdrop and
flaccid paralysis. facilitates use when
Maintain neutral function returns.
position of head. Flaccid paralysis
may interfere with
ability to support
head, whereas
spastic paralysis
may lead to
deviation of head to
one side.
 Begin active or
passive ROM to  Minimizes muscle
all extremities atrophy, promotes
(including circulation, helps
splinted) on prevent contractures.
admission. Reduces risk of
Encourage hypercalciuria and
exercises such as osteoporosis if
quadriceps/glutea underlying problem
l exercise, is hemorrhage.
squeezing rubber Note: Excessive
ball, extension of stimulation can
fingers and predispose to
legs/feet. rebleeding.

 Assist patient
with exercise and  ROM exercise helps
PAJARILLAGA, PAULA BIANCA B.
BSN 3B/B2
perform ROM in reducing muscle
exercises for both stiffness and
the affected and spasticity. It can also
unaffected sides. help prevent
Teach and contractures.
encourage patient
to use his
unaffected side to
exercise his
affected side.

Dependent:
 As indicated  To prevent and
administer IV dissolve clotting.
injection of
recombinant
tissue
plasminogen
activator (tPA)

Collaborative
 As indicated by  To provide proper
the physician stroke recovery to
refer the patient the patient since
to physical physical therapist
therapist for were responsible for
rehab rehabilitation for
mobility in the
affected area.