SUBMITTED BY: MANIA, JOYCEL G.

NCM 103 | BSN-1F

SUBMITTED TO: MR. MAGTANONG, MARK JOSEPH (FINALS) 2ND SEMESTER

NURSING CARE PLAN

Cerebrovascular Accident (CVA)
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

SUBJECTIVE: Impaired Verbal After of nursing intervention - Consider and provide for - Help in decreasing After of nursing intervention,
Communication related to the patient will establish patient’s needs. frustration when dependent the patient was able to
“Nahihirapan po ako impaired cerebral circulation, method of communication in on others and unable to establish method of
magsalita”, as verbalized by neuromuscular impairment, which needs can be - Speak straight to the patient communicate desire. communication in which
the patient loss of facial/oral muscle tone expressed. while speaking slowly. Use needs can be expressed.
and control, secondary to yes/no questions to start. - It reduces confusion or
OBJECTIVE: cerebrovascular accident anxiety and having to process
 Vital Signs (CVA) as evidenced by - Avoid talking too quickly and respond to large amount
BP: 150/100 impaired articulation; and use a normal voice or of information at one time.
PR: 74 bpm inability to speak (dysarthria); tone of voice. Observe the
RR: 30 cpm inability to modulate speech. response of the patient. - Raising one's voice may
Tem: 36.4 C annoy or offend the patient
O2 SAT: 96% - Encourage loved ones and even if the patient is not
guests to persist efforts to necessarily hard of hearing.
As manifested by: communicate with the patient
 Difficulty producing - It is important for loved
speech. ones and guests to continue
 Facial paralysis. talking to the patient to
 Muscle and facial reduce patient’s isolation,
tension. promote establishment od
effective communication and
maintain sense of
connectedness or bonding
with the family.

SUBMITTED BY: MANIA, JOYCEL G. NCM 103 | BSN-1F

SUBMITTED TO: MR. MAGTANONG, MARK JOSEPH (FINALS) 2ND SEMESTER

NURSING CARE PLAN

Cerebrovascular Accident (CVA)
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

STUJECTIVE:
“hindi niya na magalaw
masyado yung kaliwang parte
ng katawan niya” as
verbalized by the patient
OBJECTIVE:
 Limited range of
motion
 Difficulty turning
 Uncoordinated
movements
 Slowed movement
Impaired Physical Mobility
related to neuromuscular
involved by (weakness,
paresthesia, flaccid or
hypotonic paralysis, spastic
paralysis), perceptual or
cognitive impairment,
secondary to cerebrovascular
accident (CVA) as evidenced
by inability to purposefully
move involved body parts,
limited ROM, impaired
coordination, and decreased
muscle strength or control.
After of nursing intervention
the patient will be able to:
Demonstrate techniques or
behaviors that enable
resumption of activities.
Maintain position of function
and skin integrity as
evidenced by absence of
decubitus, foot drop,
contractures and so forth.
Maintain strength and
function of affected and
compensatory body parts.
- Assess degree of weakness
in both upper and lower
extremities.
- Elevate arm and hand
- Encourage patient to assist
with movement and exercises
using unaffected extremity to
support and move weaker
side.
- Assist the patient with
exercise and perform ROM
exercises for both the affected
and unaffected sides. Teach
and encourage the patient to
use his unaffected side to
exercise his affected side.
- There may be different
degrees of involvement on
the affected side.
- Promotes venous return and
helps prevent edema
formation.
- May respond as if the
affected side is no longer part
of the body and needs
encouragement and active
training to “reincorporate” it
as a part of its own body.
- Frequent repetition of
activity helps form new
neural pathways in the central
nervous system, encouraging
new patterns of motion.
Initially, extremities are
usually flaccid and tight; in
this case, ROM exercises
should be performed more
frequently.
After of nursing intervention
my goal for my patient was
partially met, as evidenced
by:
Demonstrate techniques or
behaviors that enable
resumption of activities.
Maintain position of function
and skin integrity as
evidenced by absence of
decubitus, foot drop,
contractures and so forth.
Maintain strength and
function of affected and
compensatory body parts.

SUBMITTED BY: MANIA, JOYCEL G. NCM 103 | BSN-1F

SUBMITTED TO: MR. MAGTANONG, MARK JOSEPH (FINALS) 2ND SEMESTER

NURSING CARE PLAN

Cerebrovascular Accident (CVA)
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

SUBJECTIVE:
“Hindi na rin ako makalakad
dahil hindi na makagalaw ang
pilay kong katawan” as
verbalized by the patient
OBJECTIVE:
 Inability to dress self
independently
 Inability to bath and
groom self
independently
 Inability to perform
toileting tasks
 Inability to ambulate
independently
Self-Care Deficit related to
neuromuscular impairment,
decreased strength or
endurance, loss of muscle
control or coordination,
perceptual or cognitive
impairment, pain, discomfort
and depression, secondary to
cerebrovascular accident
(CVA) as evidenced by stated
or observed inability to
perform ADLs, requests for
assistance, disheveled
appearance, and incontinence
SHORT TERM:
After of 3 hrs. of nursing
intervention the patient will
be able to verbalized proper
hygienic practices and can
identify alternative action to
performed activity of daily
living.
LONG TERM:
After 3 days of nursing
intervention the patient will
be able to performed activity
of daily living with minimal
assistance
- Assess the patient overall
condition
- Give tepid sponge bath
- Encourage the client and the
family to provide a tepid
sponge bath every day and
other hygienic practices like
hand washing, tooth brushing, - The most crucial method for
combing, nail cutting.
- Give health teaching about
the importance of the
following:
 Tooth brushing
 Hand washing
 Combing
 Nail cutting
 Take a bath
 Regular exercise of
ambulation
- To determine the patient
capability to perform ADLs.
- The patient cannot take a
bath independently. Tepid
sponge can be an alternative
way to clean the patient’s
body.
preventing the onset and
severity of disease is good
hygiene.
- Stressing this health
education helps to remind the
patient and the family why it's
important to regularly brush
their teeth, wash their hands,
comb their hair, trim their
nails, take a bath, and
exercise or walk around.
SHORT TERM:
After of 3 hours of nursing
intervention the patient be
able to verbalized proper
hygienic practices and can
identify alternative action to
performed activity of daily
living.
LONG TERM:
After 3 days of nursing
intervention the patient be
able to performed activity of
daily living with minimal
assistance.

- Provide the patient assistive - In order to assist the patient

devices such as cane or
crutches.
- Instruct the patient for
proper way of using cane or
in walking and doing ADLs.
- For the client to effectively
use the cane or crutches
appropriately.
 crutches.
- Be aware of impulsive
actions suggestive of
impaired judgment.
- Maintain a supportive, firm
attitude. Allow the patient
sufficient time to accomplish
tasks. Don’t rush the patient.
SUBMITTED BY: MANIA, JOYCEL G.
- May indicate the need for
additional interventions and
supervision to promote
patient safety.
- Patients need empathy and
to know caregivers will be
consistent in their assistance.
NCM 103 | BSN-1F
SUBMITTED TO: MR. MAGTANONG, MARK JOSEPH (FINALS) 2ND SEMESTER

NURSING CARE PLAN

Cerebrovascular Accident (CVA)
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

SUBJECTIVE: Risk for impaired Swallowing After 3-4 months of nursing INDEPENDENT: After 3-4 months of nursing
related to neuromuscular intervention the patient will - Timely intervention may intervention the patient will
“nahihirapan siyang maka- impairment, secondary to be able to improved - Have suction equipment limit the untoward effects of be able to improved
hinga at makaubo, hindi niya cerebrovascular accident swallowing, as evidenced by available at the bedside, aspiration. swallowing, as evidenced by
rin kayang kumain mag-isa” (CVA) as evidenced by absence aspiration and the especially during early absence aspiration of
as verbalized by patient’s difficulty of swallowing and risk of aspiration is decreased feeding efforts. - Promotes relaxation and evidence of coughing or
husband. rapid breathing. as manifested by reduced allows the patient to focus on choking during eating or
stasis of mucus secretions, - Provide a pleasant and the task of eating. drinking, no stasis of food in
OBJECTIVE: chances of gagging, drooping unhurried environment free of oral cavity after eating, ability
and abnormally rapid distractions. - Because alteration may to ingest foods or fluids.
 Difficulty of breathing. indicate complications like
swallowing. - Monitor the patient’s vital aspiration. Patient determines different
 Drooling sign. emergency measures when
 Stasis of mucus - To promotes lung expansion signs of aspiration occurs.
secretions in oral - Encourage deep breathing and initiates the coughing
cavity and coughing exercise reflex, which facilitates
 Gagging expectoration of mucus
 Wheezing - Place the patient in an secretion.
 Rapid breathing upright position during and
after feeding as appropriate. - To reduce the risk of
VITAL SIGNS: aspiration by use of gravity to
BP: 110/70 facilitate swallowing. Have
PR: 85 bpm the patient sit upright and
RR: 30 cpm tuck the chin towards the
Tem: 36.5 C chest as they swallow.
O2 SAT: 99%
- Provide oral care based on
individual needs before a - Patients with dry mouth
meal. require moisturizing agents
like alcohol-free
 - Feed slowly, allowing 30–
45 min for meals
- Position the patient
correctly with the head facing
to the side or on a semi/high
fowlers.
- Teach the patient and the
family on how to monitor for
signs of aspiration especially
during ngt feeding.
SUBMITTED BY: MANIA, JOYCEL G.
SUBMITTED TO: MR. MAGTANONG, MARK JOSEPH
mouthwashes before and after
eating. Patients with
excessive saliva will benefit
from the use of drying agents
before meals and
moisturizing agents
afterward.
- Feeling rushed can increase
stress and frustration, may
increase the risk of aspiration,
and may result in the patient’s
terminating meal early.
- To promote airway
clearance due to stasis of
mucus and to promote
oxygenation via maximum
chest expansion.
- Because the tip of the ngt
may be dislodged from the
stomach and lead to
aspiration.
NCM 103 | BSN-1F
(FINALS) 2ND SEMESTER
 NURSING CARE PLAN
Cerebrovascular Accident (CVA)
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

SUBJECTIVE:
“Malabo na yung mata ko, di
ko na maaninnag yung mga
malalayo” as verbalized by
the patient
OBJECTIVE:
 Wearing of eye
glasses while reading
 History of falls two
years ago
 Steady gait
Risk for falls related to
impaired vision, secondary to
cerebrovascular accident
(CVA) as evidenced by
sensory loss of part of visual
field
After of nursing intervention
the patient will make
necessary changes in the
physical environment to
ensure safety for the patient.
- Assess muscle strength,
gross and fine motor
coordination.
- Assess severity of sensory
or motor deficits;
environmental hazards, and
inadequate lighting;
medication use; improper use
of assistive devices.
- Make necessary changes in
environment (i.e., remove
throw rugs). Orient patient to
environment
- Altering coordination, gait, After of nursing intervention
and balance. the patient makes necessary
changes in the physical
environment to ensure safety
- Assessment factors will help for the patient.
identify appropriate
interventions.
- These measures prevent
injury to patient.

- Teach patient about - Overmedication in older

medications that have been adults is one of the major risk
prescribed for him or her. factors in falls

- Teach patient and family - Proper lighting is always

about the use of safe lighting. considered as a preventive
Advice patients to wear measure.
sunglasses to reduce glare.

- Encourage adult patient to - Being able to express the

express feelings about the fear will raise the nurse’s
fear of falling. awareness of what the patient
- Advice to wear proper eye considers problem areas.
glasses