Nursing Care Plan

Lipa City Colleges

“Seizure Disorder (Actual)”
Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Deficient Knowledge Short term: Independent: Short-term goal met:

“Nasa trabaho ako related to lack of
non nung mangyari exposure as After an hour or two of - Ascertain level of - To assess readiness After two hours of
yung insidente. Bigla evidenced by nursing interventions, knowledge, including to learn nursing interventions,
nalang akong naliyo questions and anticipatory needs.
at di ko mapigilan unfamiliarity with > the patient will > the patient
ang paggalaw ng resources verbalize - Determine client’s - Individual may not verbalized
mga kamay at paa understanding of the ability or readiness and be physically, understanding of the
ko. Anong disorder and various barriers to learning. emotionally, or disorder and various
nangyayari sakin? stimuli that may mentally capable at stimuli that may
Stroke po ba to?” as increase potentiate this time. increase potentiate
verbalized by the seizure activity. seizure activity.
- Discuss the - Regularity and
patient.
Long term: significance of moderation in Long-term goal met:
OBJECTIVES: maintaining good activities may aid in
- Confusion After a week of nursing general health, reducing or controlling After a week of
- Looks worried interventions, (adequate diet, rest, precipitating factors, nursing interventions,
moderate exercise, and enhancing a sense of
V/S: - the patient will avoidance of exhaustion, general well-being, - the patient initiated
Temp: 37.2°C initiate necessary alcohol, caffeine, and and strengthening necessary lifestyle or
HR: 115 bpm lifestyle or behavior stimulant drugs). coping ability and self- behavior changes as
changes as indicated. esteem. Note: Too indicated.
RR: 20 bpm little sleep or too much
Sp02: 96% alcohol can precipitate
BP: 130/80 mmHg seizure activity in
some people.

- Identify necessity and - Lessens risk of injury

promote acceptance of to self or others,
actual limitations; especially if seizures
discuss safety measures occur without
regarding driving, using warning.
mechanical equipment,
climbing ladders,
swimming, and hobbies.

- Review medication - Lack of cooperation

regimen, the necessity of with a medication
taking drugs as ordered, regimen is a leading
and not discontinuing cause of seizure
therapy without breakthrough. The
physician supervision. patient needs to know
Include directions for a the risks of status
missed dose. epilepticus resulting
from the abrupt
withdrawal of
anticonvulsants.
Depending on the drug
dose and frequency,
the patient may be
instructed to take a
 missed dose if
remembered within a
predetermined time
frame.
- Recommend taking
drugs with meals, if - May reduce the
appropriate. incidence of gastric
irritation, nausea, and
vomiting.
- Discuss nuisance and
adverse side effects of - May indicate the
particular drugs need for change in
(drowsiness, fatigue, dosage or choice of
lethargy, hyperactivity, drug therapy.
sleep disturbances, Promotes involvement
gingival hypertrophy, and participation in
visual disturbances, the decision-making
nausea and vomiting, process and
rashes, syncope and awareness of potential
ataxia, birth defects, long-term effects of
aplastic anemia). drug therapy, and
provides an
opportunity to
minimize or prevent
- Provide information complications.
about potential drug
- Knowledge of
interactions and the
anticonvulsant use
necessity of notifying
reduces the risk of
other healthcare prescribing drugs that
providers of the drug may interact, thus
regimen. altering seizure
threshold or
therapeutic effect. For
example, phenytoin
(Dilantin) potentiates
the anticoagulant
effect of warfarin
(Coumadin), whereas
isoniazid (INH) and
chloramphenicol
(Chloromycetin)
increase the effect of
phenytoin (Dilantin),
and some antibiotics
(erythromycin) can
cause elevation of
serum level of
carbamazepine
(Tegretol), possibly to
- Familiarize proper use
toxic levels.
of diazepam rectal gel
(Diastat) with the
- Useful in controlling
patient, SO and caregiver
serial or cluster
as appropriate.
seizures. Can be
administered in any
setting and is effective
usually within 15 min.
 May reduce
dependence on
emergency
- Encourage patient to department visits.
wear an identification
tag or bracelet stating - Expedites treatment
the presence of a seizure and diagnosis in
disorder. emergency situations.

Collaborative:

- Review local laws and

restrictions pertaining
to persons with epilepsy - Although legal and
and seizure disorder. civil rights of persons
Encourage awareness with epilepsy have
but not necessarily improved during the
acceptance of these past decade,
policies. restrictions still exist
in some states
pertaining to obtaining
a driver’s license,
sterilization, workers’
compensation, and
required reportability
- Stress need for routine
to state agencies.
follow-up care and
laboratory testing as - Therapeutic needs
indicated (CBC should be may change and or
 monitored biannually serious drug side
and in presence of sore effects
throat or fever, signs of (agranulocytosis or
other infection). toxicity) may develop.

“Seizure Disorder (Risk)”

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Risk for Ineffective After a week of nursing Independent: Goal met:
SUBJECTIVE: Airway Clearance interventions,
“Nasa trabaho ako related to - Monitor respiratory - Provides a baseline After a week of
non nung mangyari Neuromuscular - the patient will rate, rhythm, depth, and data for evaluating nursing interventions,
yung insidente. Bigla impairment maintain effective effort of respirations. adequacy of
nalang akong naliyo respiratory pattern ventilation. - the patient
at di ko mapigilan with airway patent or maintained effective
ang paggalaw ng aspiration prevented. - Assess client’s ability - Infections of the respiratory pattern
mga kamay at paa to cough effectively. respiratory tract can with airway patent or
ko. Anong affect the amount and aspiration prevented.
nangyayari sakin? character of mucus. An
Stroke po ba to?” as ineffective cough
verbalized by the compromises airway
patient. clearance and
prevents secretions to
OBJECTIVES: expel freely.
- Confusion - Ensure patient to the
- Looks worried empty mouth of - Lessens risk of
dentures or foreign aspiration or foreign
V/S: objects if aura occurs bodies lodging in the
Temp: 37.2°C and to avoid chewing pharynx.
HR: 115 bpm gum and sucking
RR: 20 bpm lozenges if seizures
Sp02: 96% occur without warning.
BP: 130/80 mmHg
- Maintain in lying - Helps in the drainage
position, flat surface; of secretions; prevents
turn head to side during the tongue from
seizure activity. obstructing the
airway.

- Loosen clothing from

- Aids in breathing or
neck or chest and
chest expansion.
abdominal areas.
- Provide and insert
plastic airway or soft roll - If inserted before the
as indicated and only if jaw is tightened, these
the jaw is relaxed. devices may prevent
biting of the tongue
and facilitate
suctioning or
respiratory support if
required. Airway
adjunct may be
indicated after
cessation of seizure
activity if the patient is
unconscious and
unable to maintain a
safe position of the
- Suction as needed. tongue.

- Reduces risk of
aspiration or
- Supervise asphyxiation.
supplemental oxygen or
bag ventilation as - May lessen cerebral
needed postictally. hypoxia resulting from
decreased circulation
or oxygenation
secondary to vascular
spasm during a
 seizure.
Dependent:

- Get ready for or assist

with intubation, if
indicated. - Presence of
prolonged apnea
postictally may need
ventilatory support.

“Seizure Disorder (Potential)”

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Potential to Short term: Independent: Short-term goal met:

SUBJECTIVE: Noncompliance
“Nasa trabaho ako related to financial After an hour or two of - Assess the patient’s - This allow nurses After an hour or two
non nung mangyari limitation as nursing interventions, knowledge about to explain or clarify of nursing
yung insidente. Bigla manifested by seizure, its medical information as interventions,
nalang akong naliyo inadherance to > the patient will management, and indicated and
at di ko mapigilan therapeutic regimen verbalize knowledge treatment plan. facilitates > the patient
regarding the illness development of an verbalized knowledge
ang paggalaw ng and therapeutic individualized care regarding the illness
mga kamay at paa regimen. plan that encourages and therapeutic
ko. Anong adherence. regimen.
nangyayari sakin? Long term:
Stroke po ba to?” as - Determining these Long-term goal met:
After a week of nursing - Assess for causes of causes enables the
verbalized by the
interventions, nonadherence, such as nurse to focus on the After a week of
patient.
history of patient’s care plan and nursing interventions,
OBJECTIVES: - the patient will noncompliance, provide appropriate
- Confusion recognize negative socioeconomic status, actions. - the patient
- Looks worried effects of continued forgetfulness, side recognized negative
non adhering effects of medications, effects of continued
V/S: behaviors. confusion about non adhering
Temp: 37.2°C medication instructions, behaviors.
HR: 115 bpm or difficulty making
RR: 20 bpm significant lifestyle
Sp02: 96% changes.
Enable the nurses to
BP: 130/80 mmHg
- Allow the patient to shed light on the
vent feelings such as patient’s view of
indifferent, helplessness, vulnerability to the
powerlessness, shame. disease process and
Evaluate the patient’s signs of denial of the
view of the effectiveness illness.
or ineffectiveness of the
recommended
treatment.
- Helps identify if a
- Assess the support problem in the family
system of the patient. pattern influences
patient’s
nonadherence.

- Removing and
- Explain ways of overcoming these
dealing with common barriers is vital in
problems of achieving patient’s
nonadherence such as adherence to
financial constraints and treatment.
workplace
discrimination.
- This will help
- Discuss and clarify identify factors that
myths and stigmas. Give may affect adherence
realistic assessment of such as culture,
risks, and correct spiritual belief, or
misconceptions. personal value.

- Individuals may be
- Assist in the able to understand
identification of better and feel the
available support support through the
systems such as the local experiences of others
epilepsy centers and with the same
epilepsy-specific condition.
organizations.
Dependent:
- These interventions
- Once the factors of encourages adherence.
nonadherence are
identified, discuss the
possibility of revising
the therapeutic plan
with the health care
provider. Give
instructions about
measures in controlling
the side effects of anti-
seizure medications
 Avoiding alcohol
to prevent extra
sedative effects
 Taking drug with
food to lessen
gastric upset

- Helps improve the

Collaborative:
quality of life and
psychological well-
- Suggest referral to
being of patients who
counseling or
are struggling with
psychotherapy if
disease that may be a
indicated.
reason of non-
adherence.
 “Head Trauma (Actual)”

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Deficient Knowledge Long term: Independent: Goal met:

“Naglalaba ako that
r/t lack of experience
with head injury as After a day of nursing - Assess the patient’s - Brain injury might After a day of nursing
time and madulas
talaga yung manifested by interventions, cognitive ability and affect short-term interventions,
pinaglalabahan ko. questions receptiveness to memory and cause
Pagkatayo ko para - the patient will learning information. behavior and mood - the patient
kunin yung iba pang demonstrate changes.  Ability to demonstrated
mga damit, nadulas ako knowledge about the focus and learn new knowledge about the
at nabagok ang ulo ko. disease process, information might be disease process,
Nawalan ako ng malay treatment, and difficult and take more treatment, and
at paggising ko nasa
prognosis as evidenced time. prognosis as
hospital nako. Nurse,
malala ba kondisyon by verbalizing correct evidenced by
ko? Mamamatay na ba information and posing - Assess the patient’s - Most patients and verbalizing correct
ako? ” as verbalized by appropriate and knowledge about the families have no prior information and
the patient. injury and treatment experience with head
relevant questions. posing appropriate
plan. trauma injuries. In and relevant
OBJECTIVES: most cases, these questions.
- Looks worried
types of injuries arise
from very sudden and
V/S: unexpected events.
Temp: 37.2°C
HR: 90 bpm
RR:20bpm Collaborative:
Sp02: 95%
BP: 130/90mmHg - Update patients and - Family members and
family members caregivers are a vital
regularly about changes part of the healthcare
in health status. team. They can
provide unique
information about the
patient’s baseline
before the head injury.
- Prepare the patient
- Rehabilitation can be
and family for possible
a long process that
need for physical,
goes beyond the
occupational, speech
hospital stay. Patients
therapy, and ongoing
and families need to be
home support.
aware of all members
of the healthcare team.
 The roles of significant
others might turn into
primary caregiver
roles after the patient
is discharged. Families
need help to adjust to
their new roles and
situation. 

“Head Trauma (Risk)”

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Risk for Seizures After a week of nursing Independent: Goal met:
“Naglalaba ako that related to head interventions,
time and madulas injury - Protect the patient’s - The patient might After a week of
talaga yung - the patient will airway during seizure not be able to control nursing interventions,
pinaglalabahan ko. remain free from activity. muscle movement
Pagkatayo ko para seizure activity and during a seizure. The - the patient will
kunin yung iba pang injury thereof.  tongue might pose an remain free from
mga damit, nadulas airway obstruction by seizure activity and
ako at nabagok ang falling back into the injury thereof. 
ulo ko. Nawalan ako upper airway.
ng malay at
- Note characteristics - Documenting these
paggising ko nasa during the seizure:
hospital nako. Nurse, characteristics can
malala ba kondisyon Onset help to identify the
ko? Mamamatay na Duration type of seizure and
ba ako? ” as Type of seizure allows for more
verbalized by the Behavior at the onset, specific treatment
patient. during, and after the options.
seizure.
OBJECTIVES:
- Looks worried - Maintain seizure - These
precautions. implementations
V/S: Reduce environmental reduce the risk of
Temp: 37.2°C stimuli injury during a
HR: 90 bpm Pad side rails seizure.
RR:20bpm Place the bed in the
Sp02: 95% lowest position
BP: 130/90mmHg Have suction set up and
ready if needed
Provide head protection
- These measures
- Assist the patient protect the patient’s
during the seizure. airway during and
after the seizure.

Dependent:

- Administer - Phenytoin (Dilantin)

anticonvulsants as can only be mixed with
ordered and check NS. Its therapeutic
therapeutic levels level is 10 to 20
regularly. mcg/mL. Close
monitoring for
 medication toxicity is
essential. Signs include
but are not limited to
nausea, vomiting,
restlessness,
drowsiness, and visual
changes.

“Head Trauma (Potential)”

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Potential for Acute After a week of nursing Independent: Goal met:
“Naglalaba ako that Confusion r/t interventions,
time and madulas increased - Assess the patient’s - A change in mental After a week of
talaga yung intracranial pressure - the patient will level of consciousness status might indicate nursing interventions,
pinaglalabahan ko. demonstrate a stable frequently as ordered. an increase in cerebral
Pagkatayo ko para cognitive status as pressures. - the patient
kunin yung iba pang evidenced by intact demonstrated a stable
mga damit, nadulas LOC. - Reorient the patient to - Memory might be cognitive status as
ako at nabagok ang person, time, place, and affected that requires evidenced by intact
ulo ko. Nawalan ako situation frequently. frequent repetition of LOC.
ng malay at the same information.
paggising ko nasa Informing the patient
hospital nako. Nurse, about their situation
malala ba kondisyon might reduce anxiety
ko? Mamamatay na levels and bring their
ba ako? ” as cognitive status back
verbalized by the to baseline.
patient.
- Introduce yourself - These measures are
OBJECTIVES: before any interaction part of reorientation.
- Looks worried and procedures. Explain Too much information
care in short and simple at once might increase
V/S: sentences before and confusion and make
Temp: 37.2°C throughout the process. the patient more
HR: 90 bpm irritable.
RR:20bpm
Sp02: 95% - Promote continuity of - Frequent changes in
BP: 130/90mmHg care staff and environment
might further worsen
the patient’s confused
state. Keep the staff
and environment
consistent as much as
possible.
Dependent:

- Treat the underlying

- For increased
cause of the confusion.
intracranial pressure,
implement measures
to reduce this
pressure.
Collaborative:

- If possible, have the

family communicate - Seeing familiar faces
 with the patient via and recognizing
facetime. familiar voices might
stimulate memory and
helps with
reorientation.
“Cerebrovascular Accident/Stroke (Actual)”
Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Impaired physical After a week of nursing Independent: Goal met:

“Nakawork from mobility related to interventions,
home ako that time paralysis of one side - Assess the patient’s - To assist in creating After a week of
nung nangyari ang of the body as - The patient will be level of functional an accurate diagnosis nursing interventions,
lahat. Wala pakong manifested by able to perform mobility and ability to and monitor
tulog and kain that difficulty of activities of daily living perform ADLs. effectiveness of The patient
time. Alam kong movement, unsteady within the limits of the treatment and performed activities
napapabayaan ko na gait, generalized present condition. therapy. of daily living within
ang sarili ko. Di ko weakness, inability the limits of the
sukat akalain na to do activities of - Assist the patient - To encourage the present condition.
maiistroke ako. daily living (ADLs) as during exercises and patient to perform
Biglaan ang normal, and when performing muscle-strengthening
pangyayari. As in verbalization of activities of daily living. exercises and promote
sobrang bilis. Bigla overwhelming dignity by allowing the
nalamang akong tiredness/ fatigue patient to perform
hindi makagalaw sa their ADLs while
sobrang panghihina maintaining safety.
at panginginig ng - Ensure the safety of
katawan ko. Di ko na - To maintain patient
the environment. Check
kontrolado that the call bell is safety and reduce the
paggalaw ng isang within reach, the bed risk of falls.      
bahagi ng katawan rails are up when the
ko at din a ko patient is on the bed, the
makakilos tulad ng bed is in the lowest level,
dati” as verbalized the room is well-lit, the
by the patient. floor is not slippery, and
that important things
OBJECTIVES: like phone and
- Looks sad eyeglasses are easy to
- Worried reach.

V/S: - Encourage the patient - To improve venous

Temp: 37.0°C to perform range of return, muscle
HR: 87 bpm motion (ROM) exercises strength, and stamina
RR:17 bpm in all extremities. while preventing
Sp02: 97% stiffness and
BP: 120/80mmHg contracture
deformation.

Collaborative:

- Refer to the - To provide a

physiotherapy and specialized care for the
occupational therapy patient to gain
team. physical and mental
support in performing
ADLs and mobilizing.
 “Cerebrovascular Accident/Stroke (Risk)”

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Risk for Injury After a week of nursing Independent: Goal met:
“Nakawork from related to Altered interventions,
home ako that time sensory reception, - Assess the type and - Describe right and After a week of
nung nangyari ang transmission, and/or - The patient will degree of hemisphere left hemisphere nursing interventions,
lahat. Wala pakong integration interact appropriately injury the patient injuries.
tulog and kain that with his or her exhibits. The patient interacted
time. Alam kong environment and does appropriately with his
napapabayaan ko na not exhibit evidence of - Evaluate for visual - The presence of or her environment
ang sarili ko. Di ko injury caused by deficits. Note the loss of visual disorders can and does not exhibit
sukat akalain na sensory/perceptual visual field, changes in negatively affect a evidence of injury
maiistroke ako. deficit. in-depth perception patient’s ability to caused by
Biglaan ang (horizontal and/or perceive the sensory/perceptual
pangyayari. As in vertical planes), environment and deficit.
sobrang bilis. Bigla presence of diplopia relearn motor skills
nalamang akong (double vision). and increases the risk
hindi makagalaw sa of accident and injury.
sobrang panghihina
- Assess sensory - Diminished sensory
at panginginig ng
awareness: dull from awareness and
katawan ko. Di ko na
sharp, hot from a cold, impairment of
kontrolado
position of body parts, kinesthetic sense
paggalaw ng isang
bahagi ng katawan joint sense. negatively affect
ko at din a ko balance and positioning
makakilos tulad ng and appropriateness of
dati” as verbalized movement, which
by the patient. interferes with
ambulation, increasing
OBJECTIVES: the risk of trauma.
- Looks sad
- Worried
- Encourage patients
- Patients with non-
with non-dominant
V/S: dominant (right)
(right) hemisphere
Temp: 37.0°C hemisphere injury may
injury to slow down and
HR: 87 bpm also have decreased
check each step or task
RR:17 bpm pain sensation and
as it is completed.
Sp02: 97% sense of and visual field
BP: 120/80mmHg deficit but are typically
unconcerned or
unaware of or deny
deficits or lost abilities.
They tend to be
impulsive and too
quick with movements.
Typically, they have
impaired judgment
about what they can
and cannot do and
often overestimate
their abilities. These
individuals are at risk
 for burns, bruises, cuts,
and falls and may need
to be restrained from
attempting unsafe
activities. They also are
more likely to have
unilateral neglect than
individuals with
dominant (left)
hemisphere injury.

- Remind patients who - These patients may

have a dominant (left) lack or have decreased
hemisphere injury to pain sensation and
scan their environment. position sense and
have visual field
deficits on the right
side of the body. They
may need reminders to
scan their environment
but usually do not
exhibit unilateral
neglect.
- Encourage making a
- Patients may have
conscious effort to scan
visual field deficits in
the rest of the
which they can
environment by turning
physically see only a
head from side to side.
portion (usually left or
 right side) of the
normal visual field
(homonymous
hemianopsia).

- Give short, simple - These individuals

messages or questions may have poor abstract
and step-by-step thinking skills. They
directions. Keep the tend to be slow,
conversation on a cautious, and
concrete level (e.g., say disorganized when
“water,” not “fluid”; approaching an
“leg,” not “limb”). unfamiliar problem and
benefit from frequent,
accurate, and
immediate feedback on
performance. They may
respond well to
nonverbal
encouragement, such
as a pat on the back.
- Intervene as follows
for patients with - Patients may have the
nondominant (right) following sensory
hemisphere injury: perceptual alterations:

- Keep the patient’s

environment simple to - Impaired ability to
reduce sensory overload recognize objects using
and enable senses of hearing,
concentration on visual vibration, or touch:
cues. Remove These patients rely
distracting stimuli. more on visual cues.

- Assist patients with

eating. Monitor the - Difficulty recognizing
environment for safety and associating familiar
hazards, and remove objects: Patients may
hazardous objects such not know the purpose
as scissors from the of silverware. These
bedside. patients may not
recognize hazardous
objects because they do
not know the purpose
of the object or may not
recognize subtle
distinctions between
objects (e.g., the
difference between a
fork and spoon may
become too subtle to
- Teach the patient to detect).
concentrate on body
parts - The misconception of
own body and body
parts: These patients
may not perceive their
foot or arm as part of
- Provide these patients their body.
with restraint or
wheelchair belt for - Inability to orient self
support. in space: They may not
know if they are
standing, sitting, or
- Provide a structured, leaning.
consistent environment.
Mark outer aspects of
the patient’s shoes or - Visual-spatial
tag inside the sleeve of a misconception: The
sweater or pair of pants patient may have
with “L” and “R.” trouble judging
distance, size, position,
rate of movement,
form, and how parts
relate to the whole. For
example, the patient
may underestimate
distances and bump
into doors or confuse
inside and outside of an
object, such as an
article of clothing.
These patients may
lose their
place when reading or
- Direct the patient’s adding up numbers and
attention to a particular therefore never
 sound (e.g., playing complete the task.
different musical
instruments and - Impaired ability to
associating its sound to recognize, associate, or
its name.) interpret sounds.

- Protect from
temperature extremes;
assess the environment
for hazards.
- Promotes patient
Recommend testing
safety, reducing the
warm water with
risk of injury.
unaffected hand.

“Cerebrovascular Accident/Stroke (Potential)”

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Potential for Acute After a 2-3 days of Independent: Goal met:
“Nakawork from Pain related to nursing interventions,
home ako that time stroke as evidenced - Check for the - A patient’s After a 3 days of
nung nangyari ang by the patient’s - the patient will characteristics, intensity, verbalization of pain nursing interventions,
lahat. Wala pakong verbalization of express that the pain location, and pain scale. and pain scale is one of
tulog and kain that shoulder stiffness, scale lessen. Get the vital signs of the the most accurate - the patient
time. Alam kong immobility, patient and note the ways to know a expressed that the
napapabayaan ko na spasticity, and increase in blood patient’s level of pain. pain scale lessen.
ang sarili ko. Di ko contractures. pressure, respiratory The nurse should also
sukat akalain na rate, and heart rate. check the signs of pain
maiistroke ako. Assess for hemiplegic
Biglaan ang shoulder pain which is a
pangyayari. As in common complication of
sobrang bilis. Bigla stroke that happens on
nalamang akong the side of the patient
hindi makagalaw sa that is paralyzed.
sobrang panghihina - Determining the
at panginginig ng - Ask the patient about
previous history of
katawan ko. Di ko na the history of previous
pain is important for
kontrolado pain and allergies to
developing a plan of
paggalaw ng isang medications. Check for
care. The nurse should
bahagi ng katawan the presence of the
note the previous
ko at din a ko patient’s central post-
medications the
makakilos tulad ng stroke pain syndrome.
patient used to reduce
dati” as verbalized pain and the
by the patient. effectiveness of the
previous treatment
OBJECTIVES: and management The
- Looks sad
- Worried nurse should also need
to note the allergies to
V/S: pain medications to
Temp: 37.0°C avoid possible
HR: 87 bpm undesirable effects of
RR:17 bpm the medications on the
Sp02: 97% patients. Central post-
BP: 120/80mmHg stroke pain syndrome
occurs after a
cerebrovascular
accident which is
characterized by
abnormalities in the
body parts and pain
because of
cerebrovascular
lesions.
- Evaluate the patient’s
awareness of pain, and
- Let the patient
ask the patient how the
express his/her
patient feels about the
feelings about the
pain.
pain. Gaining the trust
of the patient will help
achieve the goal of
care. Note that the
patient’s pain varies
for each patient.
- Monitor for the Encourage the patient
patient’s vital signs
regularly. - Results of the
patient’s vital signs
may be changed due to
the pain that the
patient is
experiencing. The
blood pressure, heart
rate, and respiratory
rate may increase
- Check for the need for when the patient is
sling and assistive experiencing pain.
devices.
- Using a sling for the
shoulders will prevent
dangling and promote
- Help the patient when the normal position of
changing of position is the scapula.
needed. Position the
patient’s shoulder - Never pull and lift
appropriately. the patient’s flaccid
shoulder because this
will cause pain. 
Proper ways of
positioning and
turning will prevent
overstretching of the
affected area. The
arms should be lifted
slowly and be rotated
 outward. It is also
important to elevate
the arm and hand to
prevent edema.
Change the patient’s
- Demonstrate a range
position several times
of movement exercises
to a prone position.
as a therapeutic
technique by external - This technique
rotation and holding the produces a better
humerus under the range of flexion of the
axilla. shoulders. Improper
handling of patients
- Explain to the patient
may cause tearing of
the importance of doing
the rotator cuff.
breathing exercises to
alleviate pain. - Breathing exercises
increase the resistance
of respiratory muscles
and help in alleviating
- Evaluate the
pain and provide
effectiveness of the
relaxation.
interventions by asking
the patients pain scale,
The effectiveness of
and evaluate the
the interventions will
effectiveness of the
be based on the
medications that were
patient’s verbalization
given for pain as
of reduced pain.
prescribed by the
Evaluation of the care
physician. given to the patient
will help the nurse to
formulate additional
interventions and give
medications if needed
and as prescribed by
Dependent:
the physician.

- Give pain medications

to the patient as
prescribed by the
physician. - Medications for pain
help to decrease pain
after stroke. Non-
steroidal anti-
inflammatory
medications may be
Collaborative:
given to the patient
- Encourage the after stroke.
patient’s family and
significant others to
support the patient and
- Emotional support
show an optimistic from the family and
attitude towards the significant others
patient’s condition. prevents stress,
fatigue, and
discouragement.
Providing counseling
to the family is
essential.