NURSING CARE PLAN - CVA

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Nahihilo tapos
sumasakit ang ulo
ni mama.
Nanghihina din
yung kalahating
parte ng katawan
nya. as verbalized
by the patients
daughter

Objective:
Numbness of the
face
Difficulty
speaking, walking
and moving
Loss of balance
Slow movement
limited range of
motion









Impaired physical
mobility related to
neuromuscular
impairment as
evidenced by
hemiparesis, loss
of balance and
coordination, and
limited range of
motion
Short Term:
After 8 hours of
nursing intervention,
patient will be able
to participate in the
activities and be able
to understand the
disease and her
condition

Long Term:
Maintain or improve
strength and
function of the
affected body part


Assess ability or
extent of immobility




Maintain proper
positioning

Place a pillow on the
affected part of the
body; pillow is also
placed under axilla to
abduct arm, elevate
hand and arm

Change position every
2 hours


Use footboard during
the period of flaccid
paralysis


Establish an exercise
program passive
range of motion
(both the affected
and unaffected part
To identify strengths
and weaknesses and
for comparative
baseline during
recovery

To prevent
contractures

To prevent pressure
ulcers; prevent
adduction of shoulder
and flexion of elbow



Promote venous
return and prevent
edema

Prevents contractures
and facilitates use
when/if function
returns

To maintain joint
mobility, regain
motor control,
prevent deterioration
of the neuromuscular
Short Term:
After 8 hours of
nursing intervention,
the patient verbalized
understanding of her
condition by her
gestures and was
able to participate in
the interventions give
to her. Goal met

Long Term:
Goal not met











of the body)


Give rest period to
activities


Provide positive
reinforcement during
activity




Assist to develop
balance. Encourage
and facilitate early
ambulation and other
ADLs when possible


Administer medicines
prescribed by the
doctor
system and enhance
circulation

Te help reduce
fatigue and oxygen
demand

Patients may be
reluctant to move or
initiate new activity
due to a fear of
falling; to boost their
confidence

The longer the
patient remains
immobile, the greater
the level of
debilitation that will
occur

Aids in training
neuronal pathways
enhancing motor
response


GROUP 2
BSN III-B