Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation

Diagnosis Objectives Intervention

Subjective: Impaired Hemorrhagic After 4 hours of Independent: After 4 hours of
physical stroke usually nursing nursing
“di niya na mobility r/t reproduces intervention Assess degree There may be intervention my
magalaw paresis of weakness in differing
extensive the pt. will be goal for my
masyado ung residua function able to: both upper degrees of patient was
kaliwang loss and has the and lower involvement on partially met, as
parteng slowest recovery Demonstrate extremities. the affected evidenced by:
katawan niya!” amongst all techniques or side.
as verbalized types of stroke. behaviors that Assess ability Demonstrating
by the Bleeding often enable to move and Paralysis and techniques or
informant. produces spasm resumption of change sensory loss are behaviors that
of the cerebral activities. position to contra lateral to enables
vessel and transfer and the side of the resumption of
Objective: Maintain walk, for fine brain affected activities.
cerebral
ischemia due to position of muscle by the stroke.
limited range function and movement Maintaining
blood outside the
of motion skin integrity as and for gross position of
vessels acts as
an irritant to theevidenced by muscle function and skin
difficulty movements. Impaired
tissues. absence of integrity as
turning mobility
decubitus, evidenced by
Their lumina footdrop, Monitor skin increases the absence of
uncoordinated integrity for risk for skin
narrow, with contractures decubitus,
movements areas of breakdown
resultant and so forth. footdrop,
decreased blood blanching or contractures and
slowed
to the heart, Maintain/increa redness as so forth,
movement
brain, and lower se strength and signs of
function of potential Maintaing /
extremities. As
affected and / breakdown. increasing
the damage
compensatory Patient may not strength and
continues, large body part.
Change feel increase in function of
vessels may
pressure or affected and /
become occluded position of
compensatory
or may lead to patient atleast have the ability
body part.
hemorrhage, 2hours to adjust
which cause keeping track position. Loss of
infarction of the of position motor control
 tissue supplied changes with a can contribute
by the vessel turning to abnormal
that has been schedule. posturing.
scuffed off blood
supply .

Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation

Diagnosis Objectives Intervention
Subjective: Unilateral People After 2 days of Independent: After 2 days of
neglect experiencing nursing nursing
“Parang wala related to right sided CVA intervention Approach the This decreases intervention the
na ang neuromuscu patient from pt. was able to
will develop left the pt. will be the anxiety and
lar used weak
kaliwang sided paralysis or able to move or the unaffected fear while the
impairment extremities with
bahagi ng left sided hemi use weak side. patient is unable assistance from
katawan niya, paresis due to extremities to interpret the functioning
hindi na niya cerebral artery with assistance whole extremities and
ito masyado occlusion that from environment was able to
magalaw kasi most commonly functioning As patient touched affected
nanghihina na” develop neglect, extremities and becomes more This will side during ADLs.
as verbalized which would lead touches alert, encourage the
by the client. them to failure to affected side approach to patient to use
feel stimulation during ADLs. the affected the affected
on the affected side. side of the body
Objective:
side of the body.
Hemianopsia
Left sided limits the
hemiparesis Ensure a safe patient’s ability
> Medical environment to see objects in
Defects of left by placing a the affected
Surgical Nursing;
visual field call bell on the visual field.
Woods, et al.; pp.
371; 2nd ed) clients That’s why you
Inadequate unaffected have to put a
self care side call bell to ask
for assistance
Lack of
and to prevent
positioning or
risk for falls.
safety
precautions in
This approach
regard to the Place all food diminishes
affected side in small visual deficits.
quantities, Small quantities
Consistent arranged
inattention to make it easier
simply on to delineate
stimuli on an
affected side plate. foods because
of the space
 between food
items.

Attach a watch
or bright Draws the
bracelet to the patient’s
affected arm. attention to the
affected side.
Encourage the
patient to This approach to
wash the ADLs increases
affected side the patient’s
of the body awareness of
and to dress the affected
the affected side of the body.
side of the
body first.

Teach To reduce
compensatory chance of injury
strategies and increases
such as visual visual
scanning. awareness of
entire field of
vision.

(Ref: Nursing
Care Plans;
Gulanick, Myers;
pp. 568-569; 6th
ed)
 Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation
Diagnosis Objectives Intervention
Subjective: Altered health After 4 hours of Independent: After 4 hours of
Altered health maintenance nursing nursing
“Medyo malakas maintenance reflects a change in intervention, the Help patient to Having a plan or intervention,
akong related to the an individuals patient should implement a guide is always a positive health
manigarilyo” as presence of ability to perform describe positive plan to quit good start. maintenance
verbalized by the adverse functions health smoking behaviors were
patient. personal habit necessary to maintenance Different established as
specifically maintain health or behaviours as Choose an approaches evidenced by:
smoking. wellness. The evidenced by: approach to quit appeal to different
Objective: individual may smoking individuals Verbalization of
already manifest Verbalization of strong willingness
Smokes an symptoms of the importance to Avoidance of to quit smoking to
everage of 7 existing physical quit smoking Avoid temptation is improve health
sticks a day ailment or displays temptations or tantamount to the condition
behaviors that are Understanding situations avoidance of the
strongly linked to the negative associated with vice
the disease. effects of the pleasurable
smoking effects of Oral gratifications
Nursing Care smoking helps reduce the
Plans: Nursing urge to smoke
Diagnosis and Keep oral
Intervention substitutes Breathing
handy exercises help
p. 31, 3rd Edition release tension
and overcome the
Learn relaxation urge to smoke.
techniques to
reduce urge
Reviewing the
reasons for
quitting helps
Instruct patient avoid the vices
that relapses
occur Nursing Care
Plans: Nursing
Diagnosis and
Intervention

p. 33, 3rd Edition