Nursing Care Plan For Patient With Stroke Assessment Diagnosis Outcomes Intervention Rationale Evaluation

UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)

Dr. Ortega St., Iriga City, Philippines
SCHOOL OF GRADUATE STUDIES AND RESEARCH
NURSING CARE PLAN FOR PATIENT WITH STROKE
Assessment Diagnosis Outcomes Intervention Rationale Evaluation
Subjective: Impaired physical Patient will Provide passive ROM exercises for ROM exercise helps in reducing After 2 months the
mobility, related to maintain/increase strength his left arm and leg; schedule muscle stiffness and spasticity, patient has regained
Objective: neurologic deficits and function of affected or active ROM exercises for his right minimizes muscle atrophy, and partial use of his left arm
 Inability to walk causing left compensatory body part. extremities as well as quadriceps promotes circulation. It can also and leg and is using a
 Physically weak hemiplegia and gluteal sets every 4 hours help prevent contractures. walker to move around.
 generalized during waking hours. Goal is partially met.
weakness/fatigue
Patient will participate in Encourage patient to assist with May respond as if affected side is
exercises necessary to movement and exercises using no longer part of body and needs
maintain muscle strength unaffected extremity to support encouragement and active
and tone. and move weaker side. training to “reincorporate” it as a
part of own body.
Patient will demonstrate Assist patient to develop sitting Aids in retraining neuronal
techniques/behaviours balance by raising head of bed, pathways, enhancing
that enable resumption of assist to sit on edge of bed, having proprioception and motor
activities. patient to use the strong arm to response.
support body weight and move
using the strong leg.
Objective: Impaired verbal Patient will establish Assess extent of dysfunction: Helps determine area and degree After 2 months. The
 Inability to communication, method of communication patient cannot understand words of brain involvement and patient was able to
modulate related to cerebral in which needs can be or has trouble speaking or making difficulty patient has with any or establish another method
speech injury expressed self understood. all steps of the communication of communication, such
 Inability to form process as writing.
words He was able to
Provide alternative methods of Provides communication needs of understand his
communication: writing, pictures. patient based on individual communication problem
situation and underlying deficit. and accepts it gradually.
He is slowly relearning
Patient will indicate an Talk directly to patient, speaking Reduces confusion and allays speech with little
understanding of the slowly and distinctly. Phrase anxiety at having to process and frustration.
communication problems. questions to be answered simply respond to large amount of Goal is partially met.
by yes or no. information at one time
Patient will develop a Speak in normal tones and avoid Patient is not necessarily hearing
positive attitude in talking too fast. Give patient ample impaired and raising voice may
relearning speech. time to respond. Avoid pressing for irritate or anger patient. Forcing
a response. responses can result in
frustration.
Encourage SO/visitors to persist in It is important for family

efforts to communicate with members to continue talking to
patient: reading mail, discussing patient to reduce patient’s
family happenings even if patient isolation, promote establishment
is unable to respond appropriately. of effective communication, and
maintain sense of connectedness
with family.
Respect patient’s preinjury Enables patient to feel esteemed,
capabilities; avoid “speaking down” because intellectual abilities
to patient or making patronizing often remain intact.

remarks.
Objective: Feeding self-care Patient will learn to use Arrange mealtimes so that he is To enable the patient to manage At the end of 2 months,
inability to bring deficit, related to his right hand to feed sitting up by the window in a clean for self, enhancing independence the patient is using his
food from loss of the ability to himself. and private environment. and self-esteem, reduce reliance right hand to feed himself
receptacle to mouth use the left hand on others for meeting own with little difficulty.
and arm Provide adaptive devices needs, and enables the patient to Goal is partially met.
(silverware with thick handles and be more socially active.
nonslip plates).
Encourage SO to assist with meals, Re-establishes sense of

and periodically to bring or cook a independence and fosters self-
favourite food of the patient. worth and enhances
rehabilitation process.
Encourage SO to allow patient to
do as much as possible for self.
Objective: Risk for impaired Patient will maintain skin Keep his skin clean and dry at all To prevent infection and At the end of 2 months,
Inability to change skin integrity, integrity times. development of bed ulcers. the patient’s skin has
positions related to inability to remained intact. Goal is
Stiffness of left change position Inspect skin regularly, particularly met.
upper and lower over bony prominences. Gently
extremities massage any reddened areas and
provide aids such as sheepskin
pads as necessary.
Promotes even weight
Establish and maintain a regular
schedule for turning when he is in distribution, decreasing pressure

bed. on bony points and helping to
prevent skin breakdown and
decubitus formation.
Pad chair seat with foam or water- Affected side has poorer
filled cushion, and assist patient to circulation and reduced sensation
shift weight at frequent intervals. and is more predisposed to skin
breakdown.
Provide egg-crate mattress, water To prevent pressure on

bed, flotation device, or specialized the coccyx. Pressure points over
beds, as indicated. bony prominences are most at
risk for decreased perfusion.
Circulatory stimulation and
padding help prevent skin
breakdown and decubitus
development.
Set goals with patient and SO for
participation in activities and Promotes sense of expectation of
position changes. improvement, and provides some
sense of control and
independence.

Nursing Care Plan For Patient With Stroke Assessment Diagnosis Outcomes Intervention Rationale Evaluation

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UNIVERSITY OF SAINT ANTHONY

(Dr. Santiago G. Ortega Memorial)

SCHOOL OF GRADUATE STUDIES AND RESEARCH