Assessment Diagnosis Goal Intervention Implementation Rationale Evaluation

n
Subjective Selfcare Improve Establish Rapport To gain Patient self-
deficit self-care rapport the trust of care activity
data: (None) established v/s
R/T activity patient. restored to
musculoskeletal of patient Monitor vital monitored some extent
Patient is
To check as evidenced
hemiplegic impairment signs.
by
and secondary to severity of the baseline.
verbalization
unconscious CVA. Assess for immobility
type & assessed-patient To assess
severity of can’t move right the loss of
Objective
immobility, hand and right body
data: With
impairment, leg. function.
soiled
clothes with flaccidity,
unsatisfying spascity and
appearance coordination,
with able to walk, Performed
minimal sit. passive & active
sweating ROM. To regain
with Perform the body
uncombed passive ROM functioning.
hair. to all the
limbs and
progress to
assistive and
then active Taught the
ROM in all family and
joints four patient how to To save
times a day. use assistive energy
devices like and make
Use assistive walker. patient
devices as comfortable
appropriate for with easy
ambulation, performing
clothing with activities.
zipper
closures,
personal
hygiene
articles for
brushing teeth,
combing hair,
clothing that is
easily
managed to
dress and
undress.