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Nursing Care Plan: Precipitating Factor
Nursing Care Plan: Precipitating Factor
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.