ASSESSMENT

Subjective:
Umiikot ang kanyang
mata tapos nawalan
na lang sya bigla ng
malay kaya dinala sya
naming dito as
verbalized by the son
of the patient.
Objective:

Impaired level of
consciousness
(+) General
weakness
Tremors noted on
left arm and
hands

Vital Signs:
Temp - 36.8
PR 83
RR 22
B/P - 130/90

NURSING
DIAGNOSIS
Ineffective Cerebral
Tissue Perfusion r/t
Interruption of
blood flow: cerebral
vaso-spasm
evidenced by
Altered level of
consciousness

SCIENTIFIC
BASIS
The presence of
partial blockage
of the blood
vessel can be
multifactorial.
These can be
due to
vasoconstriction,
platelet
adherence on
rough surface, fat
accumulation and
therefore
decreases
elasticity of
vessel wall
leading to
alteration of
blood perfusion
with the initiation
of the clotting
sequence. This
may later lead to
the development
of thrombus
which can be
loosened and
dislodged in
some areas of
the brain such as
mid cerebral
carotid artery
that may lead to
alteration of
blood perfusion
and further
develop to
cerebral infarct.

PLANNING
After 3 days of
holistic nursing
care the patient will
be able to:
A. Maintain
usual/improved
level of
consciousness,
cognition, and
motor/sensory
function.

INTERVENTION
1.Establish rapport

RATIONALE
1.To promote
cooperation

2.Monitor vital signs

3.Check capillary refill
and conjunctiva for
paleness
4. Elevate head of
bed
to 30 degrees as
ordered

B. Demonstra
te
stable vital signs
and absence of
signs of increased
ICP.

5.Advise patient to
have enough rest

C. Display no
Further
deterioration/recurr
ence of deficits

7.Provide and
maintain oxygen as
ordered

6. Avoid neck flexion

and extreme hip/knee
extension

8.Perform GCS
monitoring as
ordered
9.Administer
Medication as
ordered.

2.To have a baseline

data, assess
changes in
neurologic status
3.To determine
blood circulation
4.To promote
circulation
5.Enough rest is
needed to conserve
energy
6.To avoid
obstruction of
arterial and venous
blood flow
7.Aids in difficulty of
breathing
8.To detect changes
indicative of
worsening or
improving condition
9.To promote
wellness

EVALUATION
After 3 days of holistic
nursing care the patient
will be able to:
A. Maintain
usual/improved level of
consciousness,
cognition, and
motor/sensory function.
B. Demonstrate
stable vital signs and
absence of signs of
increased ICP.
C. Display no
Further
deterioration/recurrence
of deficits

ASSESSMENT
Subjective:
Nahihirapan siyang
magsalita, kung
minsan umuungol din
siya as verbalized by
the son of the patient
Objective:

(+) difficulty
in speaking
(+) weakness

slurred
speech
lethargy
irritability
unable to
express
feelings
no social
interaction
apathetic

NURSING
DIAGNOSIS
Impaired verbal
communication
related to impaired
cerebral circulation
possibly evidence
by impaired
articulation.

SCIENTIFIC
BASIS
Difficulty in
speaking function
resulting from
injury of the brain
centers. It may
involve
impairment of
ability to read
and write as well
as to speak,
comprehend and
understand
gestures bec. of
the damage of
the left
hemisphere of
the brain is
affected and
where the
Brocas area
located (principal
speech center).

PLANNING

INTERVENTION

After the provision of 1. Establish rapport.

nursing care, the
significant others will
verbalize
2. Monitor and record
understanding about V/S.
the disease.
3. Establish good
Short Term:
relationship, listening
After 8 hrs. of
carefully and
holistic N.I the client attending to clients
will establish
verbal and non-verbal
methods of
expressions.
communication in
which needs can be 4. Keep
expressed.
communication
simple, using all
Maintain eye contact modes of accessing
communication
information, visual
auditory and
kinesthetic.
Long Term:
After 3 days of
holistic N.I the
client will be able to
participate in
therapeutic
communication.
Maintain good
environment.

Enhance
participation and
communication
plan.

5.Validate the
meaning of non-verbal
communication. Be
honest if you dont
understand, seek
assistance from
others.
6.Plan for alternative
method of
communication
incorporated
information about type
of disability present.
7.Reinforce that loss
of speech does not
imply that loss of
intelligence.

RATIONALE
1. To build trusting
relationship.
2. To have baseline
data.
3. To maintain good
communication skills
with the patient.
4. Assist the pt.s
need to establish
means of
communicating.

5.Making
assumption to the
word maybe wrong.
6. Using aids in
communicating
promote learning
and recovery.

7. To limit self-pity
and depression.

EVALUATION
Short Term:
After 8 hrs. of holistic
N.I the client shall be
able to improved
communication abilities
and improved family
copping.

Long Term:
After 3 days of holistic
N.I the pt. shall be able
to indicate an
understanding of the
communication difficulty
and plans for ways of
handling.

8. Provide sufficient
time for client to
respond.

8. To give right
manner when
communicating.

9.Provide
environmental stimuli
as needed or educe
stimuli.

9. To maintain
contact with reality
and to lessen the
anxiety that may
worsen the problem.

10. Involve SO/ family

in plan of care as
much as possible.
11. Refer to
appropriate resources
(speech therapies).
12. Promote rest can
improve muscular
strength.
13. Administer
medications as
prescribed, on time.
.

10. To help the pt.

recover from his
condition and limit
deterioration
11. Speech
therapies can help
the patient to cope
from his condition.
12. To stimulate the
muscle to function
well.
13. Sometimes,
medications are
given to stimulate
the brain to function
well.

ASSESSMENT
Subjective:
Client said,
namamanhid
yung kanang
kamay ko, pero
nagagalaw ko
naman, medyo
hirap lang ako.
Objective:
Limited range of
motion (client
cant fully extend
his right arm and
hold up his right
shoulder)
Limited ability
and difficulty to
perform gross
motor skills like
extending and
lifting of the right
arms
Unsteady gait
Slowed
movement
Right arm
numbness

NURSING
DIAGNOSIS
Risk for injury r/t
numbness of right
arm.

SCIENTIFIC
BASIS
CVA can be
caused by an
occlusion in the
blood flow. This
can lead to O2
and the cause
failure to nourish
the tissues at the
capillary level
and that can
cause
neuromuscular
damage w/c can
cause impaired
physical mobility

PLANNING
Long term:
After 3 days of
holistic N.I, client
will be able to
physical mobility
Expected
outcome:
Demonstrate
resumption of
activities
Participate in
ADLs
Maintain or
muscle control

Short term:
After 8 hrs of
nursing
intervention, client
will be able to
participate in
therapeutic
regimen
Expected
outcome:
Verbalize
understanding
of the situation
Verbalization of
understanding
the therapy
Able to participate
in the interventions
rendered by the
nurse.

INTERVENTION
1.. Determine degree
of immobility
2.Observe movement
when client is
unaware
3. Support affected
part with pillows
4.Give rest periods to
activities
5.Encourage
adequate fluids and
right diet as
necessary to the client

RATIONALE
1. Establish
comparative
baseline
2.To note any
incongruence with
the reports of
abilities
3.Reduce risk of
pressure ulcers
4.To help reduce
fatigue and O2
demand
5. energy
production

EVALUATION
Long Term:
Client is able to
physical mobility as
evidenced by
resumption of
activities, participation
in his ADLs and right
arm numbness
Short Term:
The client is able to
participate on the
therapeutic regimen as
evidenced by
verbalization of
understanding of the
situation, therapy, and
he is able to participate
in the interventions
rendered by the nurse

ASSESSMENT
Subjective:
Hindi ko na
maasikaso ang sarili
ko, limitado kasi ang
galaw ko as
verbalized by the
patient.
Objective:
,with soiled clothes
,with unsatisfying
appearance
,with minimal
sweating
,uncombed hair

NURSING
DIAGNOSIS
Self Care Deficit
R/t musculoskeletal
impairment
secondary to CVA

SCIENTIFIC
BASIS
Motor deficit are
the most obvious
effect of stroke.
Symptoms are
caused by
destruction
of motor neurons
in the pyramidal
pathways (nerve
fibers in the brain
and passing
through the
spinal cord to the
motor tract.) One
of those
symptoms could
be inability to
perform ADLS

PLANNING
Short Term:
After 8 hrs of
holistic NI, pt will
be able to identify
personal resources
that can provide
assistance and be
able to verbalize
knowledge of
health care
practices.
Long Term:
After 3 days of
holistic NI, pt.
will demonstrate
techniques/ lifestyle
changes to meet
self-care needs

INTERVENTION
1.Establish rapport

RATIONALE
1.To promote
cooperation

2.Monitor vital signs

3.Assess for type
and severity
of immobility
impairment, muscle
flaccidity, spasticity
and coordination,
ability to walk, sit,
move in bed perform
4.Passive ROM to all
limbs and progress
to assistive and then
active ROM in all
joints four times a day
5.Use assistive
devices as
appropriate for
ambulation,
clothing with
zipper closures,
suction cups on
personal hygiene
articles for
brushing teeth,
combing hair,
clothing that is
easily managed to
dress and undress

2.To have a
baseline data
3.Provides data
regarding
mobility and
ability to perform
activities with in
limitations
without injury or
frustrations.
4.Promotes
circulation,
muscle tone,
joint flexibility,
prevents
contractures and
weakness
5.Provides safe
support for
immobility and
other self care
activities to
promote
independence.

EVALUATION
Short Term:
Pt shall have identified
personal resources that
can provide assistance
and be able to
verbalized knowledge
of health care practices.
Long Term:
Pt shall have
demonstrated
techniques/ lifestyle
changes to meet selfcare needs

ASSESSMENT
Subjective:
Minsan nag aalangan
ako gumalaw dahil
hindi ko maigalaw
masyado ang kanang
parte ng katawan ko
as verbalized by the
patient.
Objective:
Right
hemiplegia
Unsteady gait
Slowed
movement

NURSING
DIAGNOSIS
Risk for Injury r/t
right hemiplegia
secondary
to CVA infarct

SCIENTIFIC
BASIS
CVA pt is a t risk
for injury since it
may affect the
anterior or middle
cerebral artery
leading to an
infarction in the
motor strip of
the frontal cortex
and this may
cause
hemiparesis or
hemiplegia with
the
manifestations it
may predisposed
an individual for
any injury since
part of their body
is not functioning
well.

PLANNING
Short Term:
After 8 hrs of
holistic NI, pt will
be able to seek
help to
perform tasks that
are
beyond her
capabilities
Long Term:
After 3 days of
holistic NI, pt.
will be able to
remain
free from injury
AEB
absence of
abrasion/falls

INTERVENTION
1.Establish rapport

RATIONALE
1.To promote
cooperation

2.Monitor vital signs

3.Keep the side rails
of the bed raised
4.Remind client to
walk slowly, rest
adequately
between intervals
of walking use
effective lighting
5.Inform pts so not
to leave her in the
bathroom

2.To have a
baseline data
3.To protect from
falling out of bed
4.To prevent injury
5.For continuous
monitoring and
guidance to the
client.

EVALUATION
Short Term:
Pt shall have seek help
to perform task that
are beyond her
capabilities.
Long Term:
Pt shall have remained
free from injury AEB
absence of
abrasions/falls

ASSESSMENT
Subjective:
Medyo hirap siyang
lumunok pag
pinapakain naming
sya. As verbalized by
the son of the patient.
Objective:
difficulty
in
speaking/swallowing
weakness
headache
dizziness
blurred vision
Paralysis on right
part of the body

NURSING
DIAGNOSIS
Risk for aspiration
r/t muscle
weakness due to
swallowing paralise

SCIENTIFIC
BASIS
Risk for
aspiration
can occur when
there is loss of
protective airway
reflexes such as
seen in pt. who
are
conscious/uncon
scious from drug,
alcohol, stroke
or cardiac arrest
or in instances
when a nonfunctioning
nasogastric tube
allows gastric
content to drain
around the tube
and cause silent
aspiration.

PLANNING
After the provision
of nursing care, the
pt. risk for
aspiration will be
reduce as
manifested by:
Long Term:
After 2 day of N.I
the SO will
demonstrate
techniques to
prevent and
correct aspiration.
Maintain correct
tube/ oral feeding
Short Term:
After 3-6 hrs. of N.I
the SO will be able
to identify
causative
factors. Evaluate
presence of
neuromuscular
weakness and
degree
of impairment.
Maintain safety
measure.

INTERVENTION
1. Establish rapport.
2. Monitor and
record V/S.
3. Note level of
consciousness
and awareness of
surrounding.
4.Elevate client
highest or best
possible position
for eating and
drinking and
during the feeding.
5. Instruct the family
to avoid/ limit
activities that
increase intraabdominal
pressure.
6. Feed slowly
instruct the pt. to
chew slowly and
thoroughly
7. Give semi-solid
foods, avoid
pureed foods and
mucusproduction foods
(milk). Use soft
foods that sticks
together/ form
bolus.

RATIONALE
1. To build trusting
relationship.
2. To have baseline
data.
3. To assess
contributing factor.
4. To prevent
regurgitation of food
or fluid
5. It may slow
digestion and
increase risk
for regurgitation.
6. To avoid
aspiration.
7. To decrease risk
for aspiration and
aid swallowing effort

EVALUATION
Long Term:
After 3 days of holistic
N.I the pt. shall be able
to experience no
aspiration as evidence
by noiseless respiration,
clear breath sounds,
clear odorless secretion
Short Term:
After 8 hrs. of holistic
N.I the patient/
relative shall
be able to
avoid factors
that may cause
aspiration.

ASSESSMENT
Subjective:
Hindi ko nalang
masyado iginagalaw
ang kanang parte ng
katawan ko para di na
lang ako mahirapan
as verbalized by the
patient.
Objective:
,slight irritability
,right hemiplegia
,Muscle strength
test of right arm:0/5;
right leg:o/5;
left arm: 5/5;
left leg:5/5
,needs assistance in
performing ADLs
,decrease attention
to the affected side

NURSING
DIAGNOSIS
Risk for unilateral
neglect r/t
hemiparesis
secondary to
CVA

SCIENTIFIC
BASIS
CVA or brain
attack is a sudden
loss of function
resulting from
disruption of the
blood supply to a
part of the brain. In
an ischemic brain
attack, there is
disruption of the
cerebral bloodflow
due to obstruction
of a bloodvessel.
This can cause a
wide variety of
neurologic deficits
depending on the
location of the
lesion with which
vessels are
obstructed. A
stroke is an upper
motor neuron
lesion and results
in loss of voluntary
control over motor
movements.
Because the upper
motor neurons
decussate (cross),
a disturbance of
voluntary motor
control on one side
of the body may
reflect damage to
the upper motor
neurons on the
opposite side of the
brain. The most
common motor
dysfunction is
hemiplegia

PLANNING
Short Term:
After 8 hrs of
holistic NI, the
pt will participate in
the performance
of range of motion
exercises on the
extremities.
Long Term:
After 3 days of
holistic NI, the pt
will increase the
utilization of the
affected
extremities
with due
assistance from
the SO.

INTERVENTION
1.Established
rapport
2.Assessed patients
general physical
condition
3.Performed AM
care
4.Monitored vital
signs frequently
5.Instructed pt to a
low fat, low salt
diet with SAP
6.Performed muscle
strength test
7.Instructed pt on a
PROM on the right
extremities
8.Promoted
adequate rest
9.Assisted pt with
self-care activities

RATIONALE
1. To gain trust
2. To note for any
abnormality
3.To enhance wellbeing & provide
comfort
4.To note significant
changes in vital
signs
5. To help reduce
risk of second
attack & prevent
a rise in BP
6. To determine
muscle functioning
on the extremities
7. To increase
strength and mobility
8. To promote
comfort and
relaxation
9. To prevent injury

10.Maintain body
alignment in
functional position

10. To promote and

stimulate circulation

11.Shift pts
attention
towards the
affected side

11. To stimulate and

increase pts
awareness on the
affected side

12.Administer due
Meds

12. To treat
underlying medical
condition

EVALUATION
Short Term:
The pt shall have
participated in the
performance of range
of motion exercises on
the extremities.
Long Term:
The pt shall have
increased the
utilization of the
affected extremities
with due assistance
from the SO

ASSESSMENT
OBJECTIVE
>not changing of IV
site within 72hrs
>Repeated use of
syringes
> Urine bag lying on
the floor
> Poor isolation
precaution
>Observed poo
unhygienic practices
of health care
providers
>Observed lack of
aseptic technique in
preparing IV meds.

NURSING
DIAGNOSIS
Risk for infection r/t
Prolonged
catheterization

SCIENTIFIC
BASIS
Inadequate
protective
of defense
mechanism

PLANNING
After 8 hrs of
holistic nursing
interventions,
the patient will:

Bacterium, virus,
fungus, or other
parasites invades
the susceptible
pt. Breaks in the
integument
Invasion of
pathogens
carried through
bld. Stream or
lymphatic system

- know the proper

hand washing as
well as the
significant others.

Risk for infection

-able to know what

food he must eat

- know the sign and

symptoms of
infection and when
to report these to
the physician or
nurse

-able to increase
his fluid intake at
the range of 8-10
glasses of water
-able to take
antibiotics as
prescribed

INTERVENTION
INDEPENDENT:
-Monitor and teach
the pt. to the signs of
infection
-encouraged the pt. to
wash hands before
contact with the
patient
- Encourage intake of
protein- and calorierich foods
- Encourage fluid
intake of 2000 ml to
3000 ml of water per
day
- Teach patient to take
antibiotics as
prescribed

RATIONALE

-Any suspicious
drainage should be
cultured
- Washing between
procedures reduces
the risk of
transmitting
pathogens from one
area of the body to
another
- This maintains
optimal nutritional
status
- Fluids promote
diluted urine and
frequent emptying
of bladder; reducing
stasis of urine, in
turn, reduces risk of
bladder infection or
urinary tract
infection (UTI).
- Most antibiotics
work best when a
constant blood level
is maintained; a
constant blood level
is maintained when
medications are
taken as prescribed.
The absorption of
some antibiotics is
hindered by certain
foods; patient should
be instructed
accordingly.

EVALUATION
After 8hr. of holistic
nursing interventions,
GOAL MET, the patient
was:
- know the proper
hand washing as well
as the significant
others.
- know the sign and
symptoms of infection
and when to report
these to the physician
or nurse
-able to know what
food he must eat
especially in taking of
protein and calorie
rich foods.
-able to consumed
9glasses of water
-instructed to take
antibiotics as
prescribed