NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
 Assessment Diagnosis Background Knowledge Planning Intervention Rationale Evaluation
Any activity or task that
Subjective: Self-care deficit: an individual undertakes Goal: Within the shift,
Objective:
NURSING
throughout the course of
CARE PLAN
After, the patient will be the student nurse:
bathing /
hygiene, the day, constitutes the able to perform self-care
Patients Initials age/sex:
dressing/groomi activities of daily living. activities effectively Assessed the To facilitate
Diagnosis:
ng related to Basic activities of daily within level of own degree of necessary
living include: personal ability. individual intercventions.
neurological
hygiene and grooming; functional
impairment dressing and undressing; Objectives: level.
secondary to feeding oneself; After 2 hours of
interruption of functional transfers (e.g. comprehensive nursing
blood supply in Getting out of bed); interventions, the client Obtained To aid in
the brain caused voluntarily controlling will be able to: vital signs. assessment and
by a transient urinary and fecal wash her entire face evaluation of
ischemic attack discharge; elimination; effectively. patients
or CVA. and ambulation Because brush teeth and condition.
of poor cognition and clean them properly
thinking, the patient to decrease tartar
wasnt able to do the get access to water Established To facilitate
activity and wasnt able easily and NPI. gathering of
to meet the need in independently. data.
keeping body clean and
well groomed and
protecting the integument Encouraged
(Henderson, 1991; verbalization To facilitate
Abdellah, 1960). of feelings. assessment of
patients
condition and
effectiveness of
implemented
procedures.
Assisted
patient in To increase
performing patients self-
daily hygiene esteem.
but insisted
independence
on the client

Spoke slowly
For the patient to
and clearly.
be able to
understand and
comprehend the
statements.
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
 Assessment Diagnosis Background Knowledge Planning Intervention Rationale Evaluation
In cerebral tissue Establish To establish
Subjective: Impaired perfusion, there is a goal: Rapport nurse-patient
Objective: cerebral tissue decrease in oxygen
NURSING CARE PLAN
After 2-3 days of therapeutic
perfusion related supply which results in Nursing intervention, the relationship
Patients Initials age/sex:
to vascular the failure to nourish the pt. will demonstrate
Diagnosis:
occlusion tissues at the capillary increased perfusion as Monitor Vital To obtain
secondary to level. Blood vessels individually appropriate signs baseline data
disease process which function is to and to identify
of transient supply blood to the objective: any other
ischemic attack different parts of the After 5hrs. After 2-3 deviations from
or CVA. brain are impaired. Thus, days of Nursing normal.
the O2 supply going to Intervention, the pt. will Assist patient.
the brain is also impaired. be able to demonstrate in assuming To aid with
Proper perfusion is behaviors which may semifowlers proper perfusion
needed in order to give improve proper position w/ or flow of blood
adequate nourishment to circulation such as head midline. (circulation or
he different parts of the compliance to health venous
brain in order for it to management & therapies drainage).
function well. provided. Administer
medications as To probably
ordered such decrease cardiac
as workload and in
antihypertensi maximizing
ve or diuretics. tissue perfusion

Encourage
quiet and To conserve
restful energy which
atmosphere. could aid in
lowering the O2
tissue demand.
Exercise
The t issues may
caution in
have decreased
using hot or
sensitivity due to
cold pads.
ischemia.

Encourage use
To decrease the
of relaxation tension level
techniques or
exercises.

Discuss the To retain heat or

importance of warmth
preventing efficiently
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:

Assessment Diagnosis Background Planning Intervention Rationale Evaluation

Knowledge
Activity Infarction on the Goal: Established To gain patients
Intolerance related right hemisphere has After 3 days of Rapport Trust
to neuromuscular a contra lateral nursing intervention
impairment manifestation of the patient will Assessed V.S. To gain baseline
secondary to either left side demonstrate data
interruption of paralysis and/or increase in activity
blood supply in weakness due to left tolerance. Assessed General To note for signs
the brains neurons hemisphere Condition and symptoms
caused by transient affectation causing Objective:
the immobility After 3 hrs of Provided positive
ischemic attack or
because of stiffness nursing intervention atmosphere to minimize
CVA. of muscle and the patient will use frustration
unability to mobilize identified Promoted comfort
due to the techniques to measure and
manifestation of the enhance activity provide for relief to enhance ability to
disease condition. tolerance. of pain participate in
The nervous system activities
is made up of nerve Provided ROM
cells called neurons to promote
exercises
that serve as the circulation
communication
system of the body.
Give client
They carry messages
in the form of information that to sustain
provides
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
electrical impulses. evidence/differenc motivation
The messages move e
from one neuron to Assist client in
another to keep the learning and
body functioning. demonstrating to prevent injuries
Because neurons appropriate safety
have, limited ability measures
to repair themselves
unlike other body
tissues that is why
nerve cells cannot
be repaired if
damaged due to
injury or disease.
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:

Assessment Diagnosis Background Planning Intervention Rationale Evaluation

Knowledge
Risk for Impaired The skin is the Goal: Establish To gain pt and SOs The pt shall have
skin integrity baseline defense of After 3 days of NI, pt therapeutic trust and took actions
related to prolonged the body against will be free of the relationship cooperation regarding
bed rest and infection. Any break from skin breakages. minimizing the risk
immobility in the skin may Monitor v/s To obtain baseline
secondary to harbor Objective: data
neuromuscular microorganisms that After 4 hr of nursing The pt shall have
impairment caused may invade the intervention the Assess pts general To note for the been free from risk.
by the blood normal processing patientsrelatives will condition etiology or
insufficiency in the of the body, which take actions regarding precipitating
brains neurons due may inflict or minimizing the risk factors that can
to transient aggravate the pts through: aggravate the risk.
Ischemic attack. disease condition.
a. Turning the
patient from
side to side
b. Applying Monitor I&O To have a baseline
skin data regarding
moisturizer input and output
c. Provides
comfort
d. Flattening all Encourage To maintain
the linens increase OFI to al hydration status
least 2-3 liters per .
day

Arrange bed linens To prevent increase

pressure and reduce
risk for skin
breakage
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:

Encourage and To maintain good

assist client to blood circulation
active and passive
ROM exercises

Encourage rest To promote

opportunities optimum level of
functioning

Provided comfort To let patient feel

measures and safe and
safety comfortable

Carefully wash
and pat dry skin, To maintain skin
including skinfold moisture
area. Use
hydration and
moisturization on
all at-risk surfaces.

Assist client in To prevent pressure

changing positions ulcer
every two hours

Provided Health To lessen the pts

feeling of anxiety
information
regarding the
occurring problem
To promote rest and
Provided
pts wellness
conducive
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
environment for
resting

To promote
Encourage client adequate
to have balanced nourishment.
diet especially
with increased
intake of vitamin
C and Protein.
For proper
Monitor and replacement of fluid
Regulate IVF as losses.
per doctors order
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:

Assessment Diagnosis Background Planning Intervention Evaluation

Knowledge Rationale
SUBJECTIVE: Impaired Limitation in Short Term: Vital signs taken To provide
physical independent At the end of the and recorded baseline data
Assessment
mobility Diagnosis Planningshift the patientIntervention
purposeful physical Rationale Evaluation
SUBJECTIVE:
related to Riskmovement
for Short Term:
of the would be able Note
to for risk To evaluate
Assessed extent To identify
neuropathy as Infection
body of one moreAfter 30
increase level factors presence of
of impairment strength
manifested byrelated to
extremities. minutes
Sudden of
function from 2 torelated
0, to infection
slowed increase
interruption ofnursing where in infection. deficiency
OBJECTIVE:
movement andenvironment
blood supply tointervention,
the To determine
OBJECTIVE: 0- independent
limited range of areas of the brain family1-of use
al exposure the theof Observe for effectiveness
Reduces risk of
patient will be Assisted
localized sign of theraphy
patient
motion, due to CVA result equipment tissues
impaired able to 2- use of of infection
to impaired cerebral to reposition
at self
ischemia,
coordination and metabolism whichverbalize insertionevery two hours
personal affected parts
decrease muscle permanently understanding assistancesites. has poorer
strength and willingness
damages the brain 3- use of circulation and
secondary to to follow
tissue and produce Administer and
equipment
CVA prescribed and personal
focal neurologic instruct reduce
deficit varyingregimen. sensation to
assistancerelatives
severity that leads about the skin breakdown
4- dependent
to physical Long term: precautions
immobility. After 5 days of regarding To inform
Forthe
position
Long term: Instructed used
relatives the
nursing regimen. of side rails,risk of changes and
To promote optimal
intervention,
activity, exercise, overhead trapeze transfer
discontinuing
the patient will Explain toand the
roller pad
treatment.
be freerest,
from and sleep relatives the
signs and necessity of To promote
Encourage well being
symptoms of taking To assist if
adequate intake maximize
infection. antibiotics
of fluid andthere isenergy
a
need of
nutritious food
production
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
Review avoidance or
environmenta modification
l factors. of
environment
to reduce
incidence of
infection.

To minimize
Before and after the spread of
giving care to pathogens
the client
observe
proper hand
washing
techniques.

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Risk for Short term: Assess cough A depressed
Aspiration r/t After 8 hours of and gag coughand
depressed nursing reflex gag reflexes
cough and intervention the increases the
risk for
OBJECTIVE: gag reflex patient will be
aspiration
free from
aspiration as
evidenced by A decreased
Monitor level of level of
Long Term: consciousnes consciousnes
After 8 hours of s s is a prime
nursing factor for
intervention the aspiration
patient will be
free from Auscultate Decreased GI
motility
aspiration as bowel sounds
increases the
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
evidenced by to evaluate risk of
presence of gag bowel motility aspiration
reflex because
foods and
fluids
accumulate
in the
Assess stomach
pulmonary
status for Aspiration of
clinical small
evidence of amounts can
aspiration occur without
these
reflexes

Keep suction
This is
setup necessary to
available as maintain
needed patent
airway
Positions
patients who
have a Proper
decreased positioning
level of can
consciousnes decreased
risk for
s on their
aspiration.
sides Comatose
patients
nedd
frequent
turning to
facilitate
drainage of
Check secretions.
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
placement of
NGT before A displaced
feeding tube may
erroneously
deliver tube
Check residuals feeding into
the airway
before
feeding. Hold High
if residuals amounts of
are high. previous
residuals
indicates
Maintain delayed
upright position gastric
for 30-40 mins. emptying
after feeding
Facilitates
gravitational
flow of fluid
or food.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Risk for Long Term : Independent: Short Term
injury After 2 days of Assess the To identify outcome was
Nursing clients risk for falls achieved.
Intervention, muscle The client
the client will be strength, was able to
from injury. gross and fine reduce injury
motor through
Short Term: coordination. To minimize attaining
After 2 hours of falls and safety
Nursing Provide safety injury environment
Intervention, environment by the use of
the client will be by using padded side
 NURSING CARE PLAN

Patients Initials age/sex:

Diagnosis:
able to reduce padded side rails.
the risk for rails. That can
injury through contribute
attaining safety Discuss of to
environment by importance of occurrence
using padded monitoring of injury
side ails conditions to
the relatives
to identify
risk for falls.