RLE 002

Cebu Normal University

College of Nursing
Cebu City

Mission-Vision: “Care Using Knowledge and Compassion”

Theory-based (Betty Neuman)

NURSING CARE PLAN
Assessment 3 points Goals 2 points Interventions 4 points Bibliography
Diagnosis 3 points Theoretical Basis 2 points Evaluation 1 point 15 points

Name of Student: Rabor, Johann Margarette F

Client’s Initials: Stressor Classification: (Please check)
Age: Gender: Civil Status: Religion: ___/___ Physiological (body structure and functions)
Allergies: ______ Psychological (mental processes and emotion
Diet: ______ Socio-cultural (relationships, social expectations)
Date of Admission: ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression:
NURSING
NURSING DIAGNOSIS NURSING OUTCOME
GOALS
Mutual Planning
Interventions Actual
Assessment Diagnosis (Goal attainable
(with Rationale & Source) Evaluation
within the shift)
Subjective: Disturbed sensory After 8 hours of PRIMARY INTERVENTIONS
perception r/t Altered sensory nursing Promotive:
reception intervention the I. Establish and maintain communication with the patient.
pt. will be able to: R. even an unresponsive patient may be able to hear
S. (Doenges, Moorhouse, & Murr. 2011)
Objective: Short Term
>Regain/maintain I. Protect from temperature extremes; assess environment for
usual level of hazards.
consciousness and R. Promotes patient safety, reducing risk of injury.
perceptual S. (Doenges, Moorhouse, & Murr. 2011)
functioning
I. Observe behavioral responses: crying, inappropriate affect,
Long Term agitation, hostility, agitation, hallucination.
>Acknowledge R. Individual responses are variable, but commonalities such as
changes in ability emotional lability, lowered frustration threshold, apathy, and
and presence of
Cebu Normal University
SDF-CON-NF-7002-034-00
 Theoretical basis:
Cerebrovascular accident, also
known as stroke, cerebral
infarction, brain attack, is any
functional or structural
abnormality of the brain caused
by pathological condition of the
cerebral vessels of the entire
cerebrovascular system. It is the
sudden impairment of cerebral
circulation in one or more of
the blood vessels supplying the
brain. One of the signs and
symptoms of stroke is
hemiparesis. Hemiparesis is
weakness on one side of the
body. You can still move the
affected side of your body, but
with reduced muscular
strength. Treatment is focused
on improving feeling and motor
skills, allowing you to better
manage your daily living.
S: http://www.stroke.org/we-
can-help/survivors/stroke-
recovery/post-stroke-
conditions/physical/hemiparesis
Bibliography:
 Doenges, M.E., and Moorhouse, M.F. (2011). Nurses pocket guide: nursing diagnoses with interventions (11th ed., Ser. 2011). Philadelphia: F.A. Davis
 Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia: Wolters Kluwer Health /
Lippincott Williams & Wilkins.
 http://www.stroke.org/we-can-help/survivors/stroke-recovery/post-stroke-conditions/physical/hemiparesis
Cebu Normal University
SDF-CON-NF-7002-034-00
residual impulsiveness may complicate care.
involvement. S. (Doenges, Moorhouse, & Murr. 2011)
>Demonstrate
behaviors to Preventive:
compensate I. Eliminate extraneous noise and stimuli as necessary.
for/overcome R. Reduces anxiety and exaggerated emotional responses and
confusion associated with sensory overload.
deficits.
S. (Doenges, Moorhouse, & Murr. 2011)
SECONDARY INTERVENTIONS
Curative
I. Speak in calm, comforting, quiet voice, using short sentences.
Maintain eyecontact.
R. Patient may have limited attention span or problems with
comprehension.
S. (Doenges, Moorhouse, & Murr. 2011)
I. Ascertain patient’s perceptions. Reorient patient frequently to
environment, staff, and procedures.
R. Assists patient to identify inconsistencies in reception and
integration of stimuli and may reduce perceptual distortion of reality.
S. (Doenges, Moorhouse, & Murr. 2011)
I. Stimulate sense of touch. Give patient objects to touch, and hold.
R. Aids in retraining sensory pathways to integrate reception and
interpretation of stimuli.
S. (Doenges, Moorhouse, & Murr. 2011)
TERTIARY INTERVENTIONS
Rehabilitative
I. Note inattention to body parts, segments of environment, lack of
recognition of familiar objects/persons.
R. Agnosia, the loss of comprehension of auditory, visual, or other
sensations, may lead result to unilateral neglect, inability to
recognize environmental cues, considerable self-care deficits, and
disorientation or bizarre behavior.
S. (Doenges, Moorhouse, & Murr. 2011)