Case Scenario:

Mrs. RCS, a 78 year old female residing at Rafaela Subdivision, Makinabang, baliuag Bulacan has been admitted to your floor for rehabilitation from massive stroke. Mrs. RCS is
very slow in speech but is able to give appropriate answers. You received the patient from a local medical center. Before Mrs. RCS had this stroke, she was able to take complete
care of herself and lived by herself, according to her and her family.
Mrs. RCS now has complete paralysis on the right side of her body. Her dominant hand is her right hand. Mrs. RCS is unable to do the following for herself: feed herself, provide
hygiene, dress, use the bathroom, or simply write her name. She states she wants to get better but states she doesn't know if it will ever happen.

Assessment Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Evaluation

After 8 hours of
Subjective: Self-care deficit After 8 hours of Independent: 1. This encourage a tight and healthy
implementing nursing
related to loss of independent and relationship between nurse and
1. Establish rapport with the client. intervention, goals are
Client states she gross and fine collaborative nursing client. nurse will gain the trust of
the patient thus, allowing the client met as evidence by:
wants to get better motor skill on the intervention, the client 2. Discuss specific pathology and
but states she right side of the will: individual potentials. to communicate effectively with the
doesn't know if it body secondary to nurse.
will ever happen stroke as evidenced - verbalize knowledge 3. Educate the client and family - verbalized
members about the importance of 2. Establishing realistic expectations understanding about
by inability to feed about hemiplegia
Objective: self-management. and promotes an understanding of hemiplegia
herself, inability to - verbalize a more the current situation and needs.
do proper hygiene, rational overview on - verbalized a more
Right hemiplegia 4. Assess the level of independence
inability to dress, performing ADLs and 3. To improve self-management and rational overview on
or complete using functional independence
inability to use the future possibilities. foster transition from hospital to performing ADLs
paralysis on the measure (FIM).
bathroom, inability - demonstrate community. and future
right half of the to write, and independent feeding 5. Encourage the client to give out possibilities.
body. speech problem. 4. This aids in planning for meeting
by handling utensils maximum participation in planning - demonstrated
her treatment care plan. individual needs. It also helps in
Slow in speech (spoon), determining the capability and independent feeding
(broca’s aphasia) - demonstrate picking 6. Assist with ADLs, such as feeding, capacity of the client to perform by handling utensils
up of cup and glass grooming, bathing, and dressing. ADLs (spoon),
Conscious and Encourage independence in ADLs - demonstrated
with 8 fluid ounces of
oriented (Has the when possible. 5. Involvement provides the client picking up of cup
water,
capacity to give with an ongoing sense of control, and glass with 8
appropriate - demonstrate ingestion 7. Provide self-help devices: extensions improves coping skills, and can fluid ounces of
answers) of food safely and in with hooks for picking things up enhance cooperation with the
a socially acceptable water,
from the floor, toilet risers, long-
 manner - demonstrated
Unable to - demonstrate proper handled brushes, drinking straw, and therapeutic regimen. ingestion of food
independently shower chairs.
hand washing 6. This is to maintain self-esteem and safely and in a
perform activities
of daily living such - demonstrate drying 8. Assist with movement and Range of promote recovery, the client needs socially acceptable
as: feed, provide herself using a towel Motion exercises using unaffected to do as much as possible for manner
hygiene, dress, use - demonstrate proper extremities to support and move the themselves. - demonstrated proper
the bathroom, and maneuver of putting weaker side. hand washing
7. Enable the client to manage for self,
write since the on necessary items of 9. Maintain a supportive, firm attitude. enhance independence and self- - demonstrated drying
dominant hand is clothing Allow the client sufficient time to esteem, reduce reliance on others herself using a towel
the right hand. - demonstrate proper carry out self-tasks to the best of for meeting own needs, and enable - demonstrated proper
maneuver on taking their abilities. the client to be more socially active. maneuver of putting
off necessary items of on necessary items
clothing 10. Present positive reinforcement for 8. Encourage improvements in range of clothing
- demonstrate proper all activities attempted; note partial of motion, strength and provides - demonstrated proper
achievements. neuroplasticity
maneuver on maneuver on taking
manipulation of 11. Provide adequate rest periods, 9. Clients need empathy and to know off necessary items
clothing for toileting ensure safety and comfort of the caregivers will be consistent in their of clothing
- demonstrate proper client. assistance - demonstrated proper
maneuver of sitting maneuver on
12. Instruct the client, family, or 10. This enhances the sense of self-
on and rising from manipulation of
caregiver in energy conservation worth, promotes independence, and
toilet or commode techniques. encourages the client to continue clothing for
endeavors. toileting
- demonstrated proper
11. To prevent further stress, fatigue maneuver of sitting
Collaborative: and injury. on and rising from
13. Refer the client to a physical and 12. This enhances performance while toilet or commode
occupational therapist. conserving limited energy and
preventing an increase in the level
of fatigue.
13. Rehabilitation helps to relearn skills
that are lost when part of the brain
is damaged.
Group 4 - BSN 1B

Belas, Juliet

Cruz, Darylle

Enciso, Leika Jade

Juliano, Jaelah Faith

Santos, Faith Stephanie

Orogan, Kim Saena