Nursing care plan for stroke

Nursing (Bukidnon State University)

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 NURSING CARE PLAN

Cues Need Nursing Objective of Nursing Intervention Expected

Diagnosis Care Outcome/Evaluation

Subjective: P Impaired physical After 8 hours of Independent: After 8 hours of

“Hindi na S mobility related nursing ➢ Determine diagnosis that contributes to immobility (e.g. nursing intervention
makagalaw si Y to Neuromuscular intervention the fractures, hemi/ para/ tetra/ quadriplegia) the patient was able to:
C patient will be To identify causative/ contributing factors.
nanay simula impairment a. Maintain position
H able to:
nung na-stroke ➢ Assess nutritional status and guardian others report of energy and function
O a. Maintain
siya ” as verbalize L Hypertension level. To assess functional ability and skin
ˇ position and ➢ Determine degree of immobility in relation to functional level scale.
by the son of the O integrity.
function and To assess functional ability.
patient G Occlusion within b. Guardian able to
skin integrity
I vessels of the ➢ Assist or have significant other reposition client on a regular demonstrate techniques/
as evidenced
Obective: C brain schedule (turn to side every 2 hours) as ordered by the behaviors that will
NEED by absence of
➢ (+) General parenchyma contractures, physician. enable safe repositioning
body weakness ˇ foot drop, To provide safety. by positioning the
Safety and
➢ Tremors noted Disruption of decubitus and ➢ Provides safety measures (side rails up, using pillows to patient properly.
security
on left arm and blood supply in the so forth. support body part).
hands Maslow's brain area b. Guardian will To provide safety.
➢ Inability to hierarchy ˇ demonstrate ➢ Encourage patient’s guardian involvement in decision making
perform of needs Tissue and cell techniques/ as much as possible.
gross/fine necrosis behaviors that Enhances commitment to plan optimizing outcomes
motor skills ˇ will enable ➢ Involve guadian in care, assisting them to learns ways of
safe
➢ (+) Paralysis of Destruction of managing problems of immobility.
repositioning To impart health teaching.
left side of Neuromuscular
the body junctions
➢ functional level ˇ
scale: 4 (does Interruption in
not participate transportation of
in activity) electrical impulses
to the
neuromuscular
receptors
ˇ
MYALGIA/QUADRI
OR HEMIPLEGIA
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 Cues Need Nursing Objective of Nursing Intervention Expected
Diagnosis Care Outcome/Evaluation

Subjective: P Self care deficit : After 8 hours of Independent: After 8 hours of nursing
“Simula nung na i- S hygiene, dressing nursing ➢ Provide enteric nutrition VIA NG Tube feeding. High fowlers for at intervention the patient
stroke si nanay, na Y and grooming, intervention the least 15 minutes after feeding. was able to:
bedridden na siya” C feeding and patient will be To meet patient’s need for an adequate nutritional intake. f. meet all therapeutic
H toileting related to able to:
as verbalized by ➢ Careful I/O Monitoring and apply necessary dietary self care demands in
O Neuromuscular a. meet all
the son L restrictions To establish careful assessment on patients fluid and a complete absence
impairment therapeutic electrolyte balance.
O of self care agency
self care
Objective: G ➢ Change position at least ONCE every two hours or more often g. ABSENCE OF S&S OF
Hypertension demands in
(+) NGT insertion I when NUTRITIONAL DEFICIT.
ˇ a complete
C ab se n c needed. [Adequate nutritional
PatientCisuuensa N E eE eD d OccNluusirosnin Ob je c ti
e of To prevent decubitus ulcerations. intaEkex]pected
wgithin v e of Outcome/Evaluation
ble to: sel f ➢ Provide padding fo rNthuerseilnbogwI sn, tneerevdes n, atniok nles h. GOOD SKIN TURGOR,
Safety and vessDelisaogfnto C
S[HUYBGJ IEECNTE c a r e and other areas for possible skin abrasion.
secuP rity hesibsrain a re AfteNr 1ORhMr. oAfL URINE
I]VE: S agency T o p r o t e c t t h e p a t i e n t ’s skin integrity maintaining his first nursOinUgTPUT, ABSENCE OF
parenchyma I n dd e efen p e s ne da egan int : s t s i c k n e ss a n d in f ec ti
“➢NaAhcihcierasp MasYlow' bA.fteAr line of ● P r ov id e a lt e r n a t iv e m e t ho d s o f interEvDeEnMtioAn, ,HtYhPe
Impaired ˇverbal B1ShErN. oCfE OF ocno.mmunication, like pictures or
s aanndako s cDoimsrumputinoic ER AND
magpsareliptaa”r hieraCrc nursSin&gS OF ➢ Avnis audalucltudeisa,pgeerssthuroeusldorbedeWmOo RnsNtraatti
naotifobnlood aolnl .times. Change the diaper as patieHnYtPwOaVsOaLbElMe
,eabs ath hy of
rseulaptpeldy tino interNvUenTtiRIo tICo [Fluid
verbsaulipzepdli n He e d s TnIO, tNhAeL P r o vsi do eo nc oams mpautineicnattdioenfenceaetedds .or desires based estaabnlisdhEmleec trhoolydt
ebsy the O tlohsesborfain facial patieDnEtFwICiIl on individual situation or uTon dper rel vy ei nngt dsoe ifliicnitg. of bed eof
L o r o ra l Tl .
c➢l i e nWt . ash a re a sheets, clothes and linens providing maximum combmaulanniccaeti
O
body muscle
ˇ
tone control. esta[bAlidsehqmu c●omfAonrttiacinpdatpereavnednptiroonviodfe sfkoirn pirartiiteantito’sn ] on in iw.
G nief efedcse. s remain in contact with
O➢BJECCoTnItV Tissue and cell aettehod of hicAhBnSeEeNdCsE
I
roEl: C necrosis conmutmritiunoin tHheelppfua ltiienndt’escsrkeians finogr afrluosntrgatitimone.when cOanF be
BP: 150/100 NEED ˇ caaltion in dependent on others and unable t➢o coPmrommuontiecaatne exp rDe EssCeUdB. ITUS
washing
PR: 74 Destruction of wihnitcahken]ee Ednevs ii rr oesn.ment conducive to rest and recovery. Decrease ULCERS AND FOUL
m ediums ds. ● Talk directly to patient. Speaking slowly and directly. Use yes or no
RR: 30 Neuromuscular stimuli and Metabolic demand of the body. ODORS IN BETWEEN
T[D: R3E6S.4SING junctions ca
GbenOeOxDprSeKs T o question
c o n s to e begin
r ve with.
e n e rg y p ro m o ti n g r e s t
AND IsNed. Ia tn rde rd eu co
c eve s rcoy .n fu s io n o r an x ie t y a n d LINENS/CLOTHING AND
AGsROmOanMifIe TURGOR,
h a vi n g to p r o cess and respond to
➢ Pa s si v e R O M
NsGte]d by: l Earge
x e r acims eo us nEat r oly f m o r n in g once a day, 10 times targeting
NORMAL in f o r m a t io n a t on e t i m e .
·➢DifOfibctualtiny URINE
articles OUTPUT,
prodfuocrinclgoth ˇ ABSENCE OF ● bSoptehaukpinpenroarnmdallotwoneerseaxtnrdemavitioieds.t SKIN [Clean, Intact
Love and
ing alking too fast. Give patient
s➢peePcuht. on e at [FEEDING] n swallow up
facial belonging
clothes tension. ➢ Prepare/ ➢ Handle
·➢FaMciaalinptaar an obtain utensils
accepta Maslow's hierarchy of
ianlysis. ble food ➢ Bring food needs
·
le for to mouth
Muaspcpleeaarnadnc
vel ingestio ➢ Chew and
 Interruption in EDEMA, d. ABSENCE OF This anHgeearltthhetepaacthieinngt.when S/O is at the optimum level to skin and
transportation of HYPER DECUBITUS iasmtopliemtpim receive mucus
electrical impulses AND ULCERS AND roevetocrirecsup ● inE fnocromu aratigoen f. a m i l y members and visitors to persist efforts membrane]
to the HYPOVO FOUL ODORS loantido.n, to j. ABSENCE OF
neuromuscular LEMI IN BETWEEN reducing the risk of To edcuocmatmeutnhiecaSt/eOwwithhatthfeacptaotri senhta. ve ABDOMINAL AND
receptors C LINENS/CLOT atheromatous contributed to the client’s ilness BLADDER DISTENTION,
[Fluid HING AND fPoartmienatit Iatnids eimdupcoarttianngt
ˇ MYALGIA/QUADRI RECTAL FULLNESS AND
OR HEMIPLEGIA and SKIN [Clean, oisnn ot tfohremfamtoilydemceremabseer, siftnooctotnottinalulye PRESSURE, PAIN IN
Electro Intact skin necessary hearing etalilmkiinngatteo tthhoespeatient to
impaired and reduce patients DEFECATION [ Meeting
lyte co nt rib uisolation,
t o r y promote
f ac toestablishment
rs of effective
raising voice may c toomp rme vu en n ict ra te io
c nu rra e nd
n c e o f t h e d i s ea s e a toileting demands].
balanc m
irritate n d aip nr t oa m
in o s te
e n s e o f c o n n e ct e d n e s s o r b o
e] n di n g w i th
➢or c h an g e f o r a healthy lifestyle.
th e fa m i l y.
food andDmowuncl uoasded by russel dabon (russeldabon24@gmail.com)
➢ Pick up membrane]
food