NURSING CARE PLAN

Patient’s Name: D. A. Q. Age: 73 yrs old Date: 05/23/23

Assessment Nursing Diagnosis Objectives/Planning Intervention Rationale Evaluation

Subjective cues:
“Ni kalit ra shag kaluya
maam, kanang iyang
right side na stroke” as
verbalized by patient
SO.
Objective cues:
- Shows loss of
consciousness
- (+) Paralysis of
right side of the
body
- (+) General body
weakness
Impaired physical During my 8 hours of nursing
mobility related to care and interventions the
hemiparesis, loss of patient will be able to:
balance and
coordination, ST: Perform proper
spasticity, and positioning independently or
brain injury. with assistive devices as
needed.
LT: Participate in activities of
daily living (ADLS) and
desired activities
Maintain position of function
and skin integrity
Maintain or increase strength
and function of affected and/or
compensatory body part.
Independent:
Assess client’s
developmental level, motor
skills, ease and capability of
movement, posture, and
gait.
Evaluate for presence and
degree of pain, listening to
client description about
manner in which pain limits
mobility
Determine degree of
immobility in relation to 0-4
scale noting muscle strength
and tone, joint mobility,
balance, and endurance.
Position to prevent
contractures, relieve
pressure, attain good body
alignment, and prevent
compressive neuropathies.
To determine if pain
management can improve
mobility.
Identifies strengths and
deficits and may provide
information regarding
potential for recovery
After my 8 hours of
nursing care and
intervention the patient
was be able to:
ST: Perform proper
positioning
independently or with
assistive devices as
needed.
GOAL MET!
LT: Participate in
activities of daily living
(ADLS) and desired
activities.
Maintain position of
function and skin
integrity.

- Limited range of Support affected body parts To maintain position of Maintain or increase
motion or joints using pillows, rolls, function and reduce risk of strength and function of
foot, gel pads, foam, etc. pressure ulcers. affected and/or
compensatory body part.

Dependent: GOAL PARTIALLY

Administer thrombolytic
therapy as prescribed by
physician.
Thrombolytic therapy can
include the use of MET
medications to destroy
blood clots or prevent new
blood clots from forming.
 To develop individual
Collaborative: exercise and mobility
Collaborate with physical program, to identify
therapists in providing appropriate mobility
range-of motion exercise devices, and to limit or
reduce effects and
complication of immobility

Consult with a speech

Collaborate or advice to therapist to evaluate gag
visit a speech therapist. reflexes and assist in
teaching alternate
swallowing techniques.