Cues/Needs Nursing Diagnosis Rationale Goals and Nursing Rationale Evaluation

Objectives Interventions
Subjective: Activity Intolerance One of the After 8 hours of - Change position of - To prevent from After 8 hours of
The patient related to manifestations of nursing intervention, the patient at least unrelieved pressure nursing
verbalizes, Hemiparesis Stroke is the patient will be every 2 hours, which causes interventions, the
“nanghihina yung secondary to Mild Hemiparasis. As the able to maintain keeping track of continuous pressure goal was met, patient
kaliwang kamay ko Stroke patient’s carotid maximum level of position changes on soft tissues was able to maintain
pati yung binti”. artery was occluded function and risk of with a turning between bony maximum level of
by a plaque, this complications is schedule. prominences and function and had
induced hypoxia and reduced as hard surfaces reduced risk for
lead to ischemia to manifested by: compresses complications
the brain cells. The capillaries and manifested by:
cells of the brain - Increase Range of occludes the blood
Objective: which demands for Motion flow. If the pressure - Increase Range of
- Limited Range of oxygen lacks the is relieved, a brief Motion
Motion supply and lead to - Increase muscle period of rebound
necrosis and damage strength capillary dilation
to the tissue; infarct. occurs and no tissue
- Left sided body Multiple areas where damage occurs. If
weakness affected as such are pressure is not
the pons, thalami relieved, the micro
and basal ganglia thrombi form in the
that impaired the capillary and
neural transmission completely occlude
of nerve impulse blood flow. A blister
towards different may form initially
cranial nerves and and if there has been
sites. Blocking the damage only the
nerve impulses lead superficial tissues.
to hemiparesis which Damage to
unables the patient underlying tissues
to completely control create necrotic are of
the left side of her tissue. The necrotic
body. Later patient tissue undergoes of
was not able to inflammation as the
perform range of body tries to clear it
motion exercises and and ready the tissue
had a decreased for healing.
muscle strength
making the patient
unable to be in - Perform active and - To prevent from
mobile. passive Range of thrombus formation
Motion exercises in in the deep vein
Referrence: all extremities development of
Medical Surgical several times a day. thrombus begins by
Nursing 10th edition platelet adherence to
Brunner and the endothelium.
Suddarth Where the platelets
adhere to collagen,
adenosine
diphosphate (ADP)
is released. ADP is
also released from
the damaged tissues
and disrupted
platelets. ADP
produces platelet
aggregation that
results in a platelet
plug.

- Keep side rails up - To prevent from

and lower the bed. falls which can
happens if there is
 impaired mobility.
Having side rails up
kept the patient
stable on bed
increasing safety.

- Raise head of bed - It facilitates blood

no higher than 30 flow from brain
degrees. which prevents blood
stasis thus decreases
ICP.
 Cues/Needs Nursing Diagnosis Rationale Goals and Nursing Rationale Evaluation
Objectives Interventions
Subjective Data: Altered Stimulation of the After 1 hour of Independent: After 1 hour of
Thermoregulation: thermoregulatory nursing nursing
“Medyo giniginaw Hyperthermia related center in the interventions, the Encourage to Increasing the oral interventions, the
ako at nanghihina at to Infectious Process hypothalamus by client will be able to increase the oral fluid intake will goal was met,
mainit ang katawan endogenous Maintain body fluid intake compensate for the the patient
ko. gusto ko pyrogens are temperature within fluids loss because of maintained body
magpahinga, released in an normal range (36.5 fever by diluting the temperature within
as verbalized by the infectious process C-37.5 C) blood so that the normal range (36.5
patient. which may be blood vessels will no C-37.5 C) as
evidenced by longer constrict. manifested by :
Objective Data: elevated body Therefore, SNS will
temperature stop triggering the Temperature became
● Weak in thermoregulatory 37.1 C
appearance center to increase the
● Body Reference: temperature.
wrapped with Nursing Care
blanket Planning Guides (6th To reduce metabolic
● Pallor Ed) by Ulrich demands/ oxygen
● Flushed skin Canale. Page 575. consumption of the
on the face body because muscle
● Skin is warm Promote bedrest activity increases the
to touch metabolic rate, which
● Vital signs increases the heat
are as production, known to
follows: be the by-product of
● Temp: metabolism.
38.6°C
● RR:21bpm To decrease
temperature by
means through
evaporation and
 conduction. Alcohol
sponge is not
recommended
because the alcohol
Provide tepid Sponge fumes may be
Bath instead of absorbed through the
alcohol sponges skin or lungs.

Surface cooling
promotes heat loss
by means of
radiation and
conduction. Heat will
be transferred away
from the surface of
one object to the
Promote surface surface of another
cooling by means of without the contact
undressing between the two
objects (radiation);
also, heat will be
transferred from one
molecule to a
molecule of a lower
temperature
(conduction).

Increasing fluid
intake lessens the
possibility to become
dehydrated.
 Paracetamol is an
effective analgesic-
antipyretic drug for
fever and discomfort
associated with
bacterial and viral
Discuss with the infections.
client/ SO the
importance of
increasing fluid
intake

Collaborative:
Take medicines as
prescribed such as
paracetamol

Patrick A. Pantua

BSNIV-A01

Group 3