NURSING CARE PLAN

Assessment Cues Nursing Diagnosis (Rationale) Desired Outcome Nursing Intervention Justification Evaluation
Pathophysiologic /
Schematic Diagram
Subjective: Precipitating Factor: After 8 hours of nurse Independent Goal Partially Met
Impaired Physical patient-interaction the
“Bag-o pa man Mobility related Genetic History patient will be able to:  Assess the extent of  Identifies strengths and Patient partially maintain
kami di nag abot ni to: Neuromuscular Environmental Factors impairment initially deficiencies that may optimal position of
Nanay sa involvement: right SHORT TERM and functional ability. provide information function.
emergency room ga sided weakness as Classify according to a regarding recovery.
 Patient will
reklamo na sa evidenced by Predisposing Factor: 0–4 scale. Assists in choice of “ Daw medyo indi ya pa
maintain optimal
sakon na indi nya inability to interventions because giyapon maano gid iya
position of
na kuno magiho iya purposefully move Presses on nearby cranial different techniques are nga tiil, t kai indi pa ya
function as
kamot kag tiil sa within the physical nerves or brain tissue used for flaccid and gid kaya gid, pero ga try
evidenced by
tuo nga parte sang environment; spastic paralysis. man sa.” As verbalized
absence of
iya nga lawas” as impaired by patient’s SO.
contractures,
verbalized by the coordination; Causing Subarachnoid  Monitor the lower  Bed rest puts patients at
foot drop.
patient’s significant limited range of hemorrhage extremities for risk for the development
 Patient will
others. motion; symptoms of deep vein thrombosis. Goal Met
demonstrate
decreased muscle of thrombophlebitis.
techniques/behav
Objective: strength/control Increase in ICP resulting Patient will demonstrate
iors that enable
from sudden entry of blood techniques/behaviors that
resumption of
Admitting
into the subarachnoid space
activities.  Observe the affected enable resumption of
side for color, edema,  Edematous tissue is activities.
Diagnosis: Definition: more easily traumatized
LONG TERM or other signs of
CVA vs Bleed Injuries of brain tissue: or compromised and heals more slowly.
A modification in by secondary circulation. “Biskan amo na ni
 Patient will
(+) right sided movement or Ischemia of the brain sitwasyon ni Nanay, ga
weakness maintain/increas
mobility can either resulting from the reduced tinguha gid sya gyapon
(+) nausea and e strength and
be a transient, perfusion pressure na gihoon ni iya nga tuo
vomiting function of
recurring, or more nga kamot kag tiil, kay
affected or
permanent  Inspect skin regularly,  Pressure points over gusto nya gid mag-ayo.
compensatory
dilemma. And severe headache associated particularly over bony bony prominences are As verbalized by the SO.
 BP – 170/80 body part.
when it occurs, it with episodes of vomiting prominences. Gently most at risk for
mmHg becomes a and right sided weakness massage any reddened decreased perfusion.
 HR – 64bpm complex health Circulatory stimulation
 RR – 20cpm care problem that  Patient will areas and provide aids and padding help
 Temp – 36.5 involves many maintain skin such as sheepskin pads prevent skin breakdown
 O2sat - 95% at different members integrity. as necessary. and decubitus
room air of the healthcare Impaired Physical Mobility development.
team. In fact, some related to: Neuromuscular
Creatinine 0.88 degree of involvement: right sided
immobility is very weakness as evidenced by  Change positions at  Frequently changing the
common in most inability to purposefully least every 2 hr (supine, position of the patient
BUN 12.55 conditions such move within the physical side-lying) and can reduce the risk of
ALT 28.50Na+ as stroke, environment; impaired possibly more often if tissue injury. Place a
144.50 leg fracture, multip coordination; limited range placed on the affected pillow between the legs
le sclerosis, of motion; side. of the patient before
K+ 3.11 trauma, and decreased muscle strength/ placing them in a side-
morbid obesity. control lying position. The
Chloride 106 upper thigh should not
be acutely flexed to
Source/Reference promote venous return
Strength: NANDA and prevent edema. The
Intact family patient may be turned
support. from side to side if
tolerated unless
sensation is impaired.
Weakness: The amount of time
Current medical spent on the affected
condition side should be limited
because of poorer
circulation, reduced
sensation, and more
predisposition to skin
breakdown.

 Position in prone
position once or twice a  For several 15 to 30
day if the patient can minutes times a day, the
tolerate. patient should be placed
in a prone position with
a pillow placed under
the pelvis. This position
helps in normal gait
 through hyperextension
of the hip joints and
helps in preventing knee
and hip flexion
contractures.

 Prop extremities in  Prevents contractures

functional position; use and foot drop and
footboard during the facilitates use when the
period of flaccid function returns. Flaccid
paralysis. Maintain a paralysis may interfere
neutral position of the with the ability to
head. support the head,
whereas spastic
paralysis may lead to
deviation of head to one
side.

 Place a pillow under  Helps prevent adduction

the axilla to abduct the of the shoulder and
arm. flexion of the
elbow. When the patient
is in bed, place a pillow
in the axilla when there
is limited external
rotation to keep the arm
away from the chest.
Place a pillow under the
arm while it is in a
neutral position, with
the distal joints of the
arm positioned higher
than the more proximal
joints.
 Elevate arm and hand  Promotes venous return
and helps prevent edema
formation.

 Place hard hand-rolls in  Hard hand rolls decrease

the palm with fingers the stimulation of finger
and thumb as opposed. flexion, maintaining
finger and thumb in a
functional position. If
the upper extremity is
spastic, a hand-roll is
not used because it
stimulates grasp
reflex. Alternatively,
place the hand with the
palm facing upward,
and the fingers are
placed that they are
barely flexed. Every
effort is made to prevent
edema of the hand.

 Place knee and hip in

an extended position.  Maintains functional
position.

 Maintain leg in neutral

position with a  Prevents external hip
trochanter roll. rotation.
  These are measures to
 Position the patient and prevent pressure ulcers.
align his extremities
correctly. Use high-top
sneakers to prevent foot
drop, contracture,
convoluted foam,
flotation, or pulsating
mattresses or
sheepskin.

 Begin active or passive  Active ROM exercises

range-of-motion maintain or improve
(ROM) exercises on muscle strength,
admission to all minimizes muscle
extremities (including atrophy, promote
splinted). Encourage circulation, and helps
exercises such as prevent contractures.
quadriceps/gluteal Passive ROM exercises
exercise, squeezing a help maintain joint
rubber ball, an flexibility. Affected
extension of fingers extremities are put
and legs/feet. through passive ROM
exercises about five
times a day to maintain
joint mobility,
flexibility, prevent
contractures, prevent
deterioration of the
neuromuscular system,
enhance circulation, and
regain motor control.
Exercises help prevent
venous stasis and
decrease the risk of
venous
thromboembolism.
 Encourage patient to  May respond as if the
assist with movement affected side is no
and exercises using longer part of the body
unaffected extremity to and needs
support and move encouragement and
weaker side. active training to
“reincorporate” it as a
part of its own body.

 Assist the patient with

exercise and perform  Frequent repetition of
ROM exercises for activity helps form new
both the affected and neural pathways in the
unaffected sides. Teach central nervous system,
and encourage the encouraging new
patient to use his patterns of motion.
unaffected side to Initially, extremities are
exercise his affected usually flaccid and tight;
side. in this case, ROM
exercises should be
performed more
frequently.

 Use the “start low and

go slow” approach  Frequent short periods
during exercise. of exercise are always
encouraged compared to
more extended periods
at infrequent intervals.
Improvement in muscle
strength and
maintenance of the
patient’s range of
motion and flexibility
 can only be achieved
through daily exercise.

 Monitor patient for  With exercise, shortness

signs and symptoms of breath, chest pain,
of pulmonary cyanosis, and
embolism or cardiac increased pulse rate may
overload during indicate pulmonary
exercise. embolism or excessive
cardiac workload.
Dependent

 Provide egg-crate  Promotes even weight

mattress, water bed, distribution, decreasing
flotation device, or pressure on bony points
specialized beds, as and helping to prevent
indicated. skin breakdown and
decubitus formation.
Specialized beds help
with positioning,
enhance circulation, and
reduce venous stasis to
decrease the risk of
tissue injury and
complications such as
orthostatic pneumonia.