VII.

NURSING MANAGEMENT
A.IDEAL NURSING INTERVENTIONS

Nursing Diagnosis

Nursing Interventions:

Activity Intolerance related

to right side body paralysis

1. Assess patients level of

functioning using the
functional mobility scale
2. Encourage bed exercises

3. Provide emotional support

and encouragement.

4. Turn and position patient at

least every hours

5. Involve patient in cure

related to planning and
decision making

Nursing Diagnosis

Nursing Interventions:

Rationale

To determine patients
capabilities

Prepares patient for late

activities but also offers
hope ascends of
optimism about
recovery.

To help improve
patients self-concept
and motivation to
perform

Turning helps prevent

skin breakdown by
relieving pressure

To improve compliance

Rationale

Self care deficit related to

musculoskeletal impairment

1.Observe, document and

report patients functional and
perceptional or cognitive ability
daily

Careful observation
helps you adjust
nursing actions to
meet patients needs

Applying therapy
consistently aids
patients independence

This allow patient to do

as much as possible
for self

To aid comprehension

Provides expert
assistive for
developing therapy
plan and identifying
special equipment.

2. Perform the prescribed

treatment for the underlying
condition. Monitor patients
progress and report favorable
and adverse responses

3. Provide assistive devices at

each meal as needed

4. Encourage patient to do as
much for self as possible,
giving simple instructions one
at a time

5. Consult with physician with

physical/occupational therapist

Nursing Diagnosis

Nursing Interventions:

Ineffective Tissue Perfusion

related to interruption of
blood flow

1.Elevate head of bed and

maintain head/neck in

Rationale

To promote
circulation/venous

midline or neutral position

drainage

2. Keep environment and

patient quiet, space nursing
interventions

This measures reduce

intracranial pressure

3. Maintain adequate
nutrition

To promote tissue
healing, oxygenation
and metabolism

Mobilizes excess fluid

oliguric renal failure or
edema and prevents ICP

Reduces hypoxia which

can cause cerebral
vasodilation and
increase
pressure/edema
formation

4. Administer diuretics such

as manitol as ordered

5. Administer supplemental
oxygen as indicated

Nursing Diagnosis

Nursing Interventions:

Impaired verbal
communication related to
impaired cerebral circulation

1. Review history for

neurological conditions that
could affect speech such as
stroke, tumor, MS, hearing
or vision impairment.

2. Ascertain that you have

Rationale

To assess
causative/contributing
factor

To assist client to

clients attention before

communicating.

3. Establish relationship with

the client, listening carefully
and attending to clients
verbal or non verbal
expression.

establish a means of
communication, to
express needs, wants,
ideas and questions.

To conveys interest and

concern

4. Maintain eye contact

preferably at clients level.

To establish
communication

5. Keep communication
simple, speaking in short
sentences, using
appropriate words.

To establish means of
communication

6. Plan for alternative

methods of communication
eg. Slate board,
letter/picture board and etc.

Nursing Diagnosis

Nursing Interventions:

Decarease Cardiac Output

related to altered stroke
volume

1.Determine vital
signs/hemodynamic
parameters including cognitive
status

2. Keep client on bed rest in

position of comfort

Rationale

To provide baseline for

comparison to follow
trends and evaluate
response to
interventions
Decrease oxygen
consumption and risk
for decompensation

3. Administer high flow oxygen

via mask as indicated

To increase oxygen
available for cardiac
function or tissue
perfusion.

4. Monitor vital signs

frequently

To note response to
intervention

5. Monitor cardiac rhythm

continuously

To note effectiveness of
medication

6. Decrease stimuli; provide

quite environment

To promote adequate
rest

Nursing Diagnosis

Nursing Interventions:

Acute Pain related to

inflammation of the veins

1.Assess for referred pain

as appropriate

2. Note clients attitude

toward pain and use of pain
medication

To assess
etiology/precipitating
factor

3. Obtain client assessment

of pain to include location,

To rule out worsening of

underlying condition or

Rationale

To help determine
possibility of underlying
condition

characteristics, onset and

duration, frequency, quality
and intensity

development of
complication

4. Use pain rating scale

appropriate for age and
cognition

To evaluate clients
response to pain

5. To monitor skin color and

vital signs

This are usually altered in

acute pain

To promote
pharmacological pain
management

7. Instruct in and encourage

use of relaxation techniques
such as deep breathing and
diversional activities

To destruct attention and

reduce tension

8. Administer analgesics

To maintain acceptable
level of pain

6. Provide comfort
measures, quite
environment and calm
activities

B. ACTUAL NURSING CARE PLAN

S

No subjective cues

>slurred speech noted

>right hemiplegia
> BP 150/100mmHg

Decrease Cardiac Output related altered stroke volume

Long term: At the end of 2 days of nursing interventions, patient will be

able to display hemodynamic stability
Short term: At the end of 8hrs nursing interventions, patient will be able to
maintain BP within normal range

>Vital signs taken and recorded

>Provided adequate rest
>Placed patient in high-fowlers position
>Encouraged passive ROM on the affected area and active ROM
exercises on the affected area
>Encouraged adequate rest periods.
>Encouraged to eat foods low in fat and salt
>Provided a quite and calm environment
>instructed to avoid activities that can stimulate valsalva maneuver
COLLABORATIVE:
>Administer antihypertensive drugs

>Latest BP= 150/100mmHg

>still hemiplegic, and with slurred speech

No subjective cues

>slurred speech
>right hemiplegia
>BP : 150/100 mmHg
>HGT : 201mg/dL

Ineffective tissue perfusion related to interruption of blood flow

Long term: At the end of 2 days of nursing interventions, patient will be

able to maintain adequate tissue perfusion
Short term: At the end of 8 hours nursing interventions, patient will be able
to improve tissue perfusion

>vital signs taken and recorded

>provided adequate bed rest
>assisted to perform active ROM exercises
>IVF regulated at desired rate
>change position every two hours
>Instructed proper diet, restriction to sweet, salty and high fat foods.
Collaborative Intervention:
>administer antihypertensive drug

S
O

BP : 150/100 mmHg

No subjective cues
>Right hemiplegia

Activity Intolerance related right side body paralysis

Long Term: At the end 2 days of nursing interventions, patient will report
measurable increase in activity intolerance.
Short term: At the end of 30 minutes of nursing interventions, patient will
demonstrate a decrease in physiological signs of intolerance

>Assessed patients ability to perform normal tasks noting reports of

weakness, fatigue and difficulty accomplishing tasks
>Elevated head of the bed as tolerated
>Recommended quiet atmosphere; bed rest if indicated.

>Changed position slowly; monitor for dizziness

>Planed activity progression with patient, provide assistance with
activities
E

Still with right hemiplegia

No subjective cues
S
O

> right hemiplegia

A Self care deficit related to musculoskeletal impairment

P Long Term: At the end 2 days of nursing interventions, patient will be able to
perform self care activities with assistance
Short term: At the end of 30 minutes of nursing interventions, patient will be
able to know the importance of proper hygiene
I

>bedside care done

>needs attended
>emphasized the importance of proper hygiene
>kept back dry

>assisted client in performing self care

E Able to understand the importance of proper hygiene

No subjective cues
S
O

Redness noted at the right arm

Facial grimace
A Acute pain related to the inflammation of the viens
P Long Term: At the end 2 days of nursing interventions, patient will report relief
of pain
Short term: At the end of 30 minutes of nursing interventions, patient will have
feeling of reduce pain.
I

>bedside care done

>assessed pain scale
>vital signs taken and recorded
>encouraged deep breathing technique

>encouraged diversional activities

>applied warm compress on the affected area
>provided comfort measures
E Still with redness on the right arm.

No subjective cues
S
O

Slurred speech

A Impaired verbal communication related to impaired cerebral circulation

P Long Term: At the end 2 days of nursing interventions, patient will indicate
understanding of the communication difficulty and plans ways of handling
Short term: At the end of 30 minutes of nursing interventions, patient will
establish method of communication in which needs can be expressed
I

>Established relationship with the client, listening carefully and attending to

clients verbal or non-verbal expression.
> Maintained eye contact preferably at clients level.
> Kept communication simple, speaking in short sentences, using

appropriate words.
> Planned for alternative methods of communication eg. Slate board,
letter/picture board and etc.
>Provided reality orientation by responding simple and honest statements
E Patient was able to established method of communication