Assessment

Subjective:
Ok lang
ako.
Kailangan
kong kumilos
at marami pa
akong
gagawin

Objective:
Inappr
opriate use
of defense
mechanisms
Inabili
ty to
cope/difficul
ty asking for
help
Chang
e in usual
communicati
on patterns
Inabili
ty to meet
basic
needs/role
expectations

Nursing
Diagnosis
Ineffective
coping
related to
situational
crisis:
hospitalizatio
n, body
weakness and
change in
cognitive and
sensory
perception

Scientific
Analysis

Goals/Objectives

Movement and
After 4 weeks of
sensation for one
nursing
side of the body is intervention client
controlled by the
will:
opposite side of

Talk/comm
the brain.
unicate with
Some problems
SO about
that happen after
situation and
stroke are more
changes that
common with
have occurred.
stroke on one side
Verbalize
of the brain than
awareness of
the other.
own coping
The right side of
abilities.
the brain controls
Meet
the ability to pay
psychological
attention,
needs as
recognize things
evidenced by
you see, hear or
appropriate
touch, and be
expression of
aware of your
feelings,
own body.
identification
of options, and
use of
resources.

Interventions
Assess extent of altered
perception and related degree of
disability. Determine Functional
Independence Measure score.
Identify meaning of the
dysfunction and change to
patient. Note ability to understand
events, provide realistic
appraisal of the situation.

Determine outside stressors:

family, work, future healthcare
needs.

Provide psychological support and

set realistic short-term goals.
Involve the patients SO in plan of
care when possible and explain his
deficits and strengths.
Encourage patient to express
feelings, including hostility or
anger, denial, depression, sense of
disconnectedness.

Rationale

Evaluation

Determination of individual
After 4 weeks of
factors aids in developing plan nursing intervention
of care/choice of interventions
client will:
and discharge expectations.

Talk/communic
Some patients accept and
ate with SO about
manage altered function
situation and
effectively with little
changes that have
adjustment, whereas others
occurred.
may have considerable

Verbalize
difficulty recognizing and
awareness of own
adjust to deficits. In order to
coping abilities.
provide meaningful support

Meet
and appropriate problempsychological
solving, healthcare providers
needs as
need to understand the
evidenced by
appropriate
meaning of the
expression of
stroke/limitations to patient.
feelings,
Helps identify specific needs,
identification of
provides opportunity to offer
options, and use
information and begin
of resources.
problem-solving. Consideration
of social factors, in addition to
functional status, is important
in determining appropriate
discharge destination.
To increase the patients sense
of confidence and can help in
compliance to therapeutic
regimen.
Demonstrates acceptance
of patient in recognizing and
beginning to deal with these
feelings.

Acknowledge statement of feelings

about betrayal of body; remain
matter-of-fact about reality that
patient can still use unaffected
side and learn to control affected
side. Use words (weak, affected,
right-left) that incorporate that
side as part of the whole body.

Helps patient see that the

nurse accepts both sides as
part of the whole individual.
Allows patient to feel hopeful
and begin to accept current
situation.