NURSING CARE PLAN

Pt name: R.Asperin AGE: 63 DIAGNOSIS: CVA

Assessment Nursing Dx Inference Goals Intervention Rationale Evaluation
Subjective: Ineffective tissue CVA can be Long term: Independent: Independent: Long term goals
• Client said, perfusion (cerebral) caused by an After 4 days of nursing 1. Assess the client first 1.To establish partially met:
“namamanhid r/t interruption of occlusion in the intervention, client will 2. Take note of lab results comparative baseline The pt is not able to fully
yung kanang blood flow blood flow. This be able to demonstrate ↑ and v/s 2.To know if the pt’s demonstrate ↑ perfusion
kamay ko, pero (occlusive disorder) can lead to ↓O2 perfusion 3. Review of diagnostic condition is getting as evidenced by:
nagagalaw ko as evidenced by and the cause Expected outcome: studies done better or not • Skin is still not
4. Determine voiding 3.To determine the
naman xha right arm numbness failure to nourish •Normal I/O (e.g. warm to touch (35.9
the tissues at the patterns severity of the
medyo hirap lng 1500:1500) ºC body temperature)
5. Measure extremities’ condition
ako.” capillary level •↓ motor response • Imbalanced I/O
circumference
•Absence of arrhythmia 4.To compare past fluid (output is 300ml and
6. Measure I/O
Objective: Short term: status to the current intake is 900ml)
7. Elevate HOB especially
• Arrhythmias After 8 hrs of nursing at sleep time 5.To identify if there is • ↑motor response
(atrial fibrillation) intervention, client will 8. Encourage relaxation edema (↓ numbness)
• Skin be able to participate in 9.Encourage warm 6.To monitor fluid • Presence of
temperature therapeutic regimen and dressings and preventing balance arrhythmia
changes (body to increase skin and body exposure to cold 7.To promote Short term goals
temperature is temperature 10. Perform health circulation and partially met:
36.2 ºC) Expected outcome: teaching about: venous drainage The client is able to
• Oliguria • Verbalization of • The signs and 8.↓ tissue O2 demands participate on the
(output is 250ml understanding the symptoms of the 9.To retain heat more therapeutic regimen as
condition (paralysis, efficiently
and intake is condition evidenced by
low skin and body 10. To equip client with verbalization of
850ml) • Skin and body temp) adequate knowledge understanding of the
temperature is normal • When to regarding his condition, and when to
• Verbalization of contact HC provider condition
understanding of (when symptoms are contact HC provider and
Dependent:
when to contact HC getting worst) the client does not return
1.To promote healing
provider Dependent: to normal temperature
effectively
1. Administer appropriate
medications as ordered