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 warm
naman xha right arm numbness failure to nourish  Normal I/O (e.g. 4. Determine voiding 3.To determine the to touch (35.9 ºC
the tissues at the patterns severity of the
medyo hirap lng 1500:1500) body temperature)
5. Measure extremities’ condition
ako.” capillary level  ↓ motor response  Imbalanced I/O
circumference
 Absence of 4.To compare past fluid (output is 300ml and
6. Measure I/O
Objective: arrhythmia status to the current intake is 900ml)
7. Elevate HOB especially
 Arrhythmias Short term: at sleep time 5.To identify if there is  ↑motor response (↓
(atrial fibrillation) After 8 hrs of nursing 8. Encourage relaxation edema numbness)
 Skin temperature intervention, client will 9. Encourage warm 6.To monitor fluid  Presence of
changes (body be able to participate in dressings and preventing balance arrhythmia
temperature is therapeutic regimen and exposure to cold 7.To promote Short term goals
36.2 ºC) to increase skin and body 10. Perform health circulation and partially met:
 Oliguria (output temperature teaching about: venous drainage The client is able to
is 250ml and Expected outcome:  The signs and 8.↓ tissue O2 demands participate on the
intake is 850ml)  Verbalization of symptoms of the 9.To retain heat more therapeutic regimen as
understanding the condition (paralysis, efficiently evidenced by
low skin and body 10. To equip client with verbalization of
condition
temp) adequate knowledge
 Skin and body  When to contact HC
understanding of the
temperature is normal regarding his condition, and when to
provider (when condition
 Verbalization of symptoms are getting contact HC provider and
Dependent: the client does not return
understanding of worst) 1.To promote healing to normal temperature
when to contact HC Dependent: effectively
provider 1. Administer appropriate
medications as ordered