Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Analysis
Subjective: ( no Inflammation Short term Independent: After 4 hours of nursing
Ineffective
verbal output) reaction can  Maintain airway intervention the patient
airway
occur in alveoli patency Adequate hydrate the Systemic hydration was able to :
clearance
Objective: producing  Expectorate/ patient keeps secretions
related to
exudates clear secretion moist and easier to Demonstrated
 Presences bronchocons
interfere the readily expectorate. diaphragmatic breathing
of triction,
diffusion of  Demonstrate and coughing
adventitiou increased
oxygen and reduction of Teach and encourage This technique helps
s breath mucus
carbon dioxide. congestion with the use of to improve ventilation Gives times to sleep
sound production,
Some areas in breath sound, diaphragmatic and mobilized
(rhonchi) ineffective
the lung may respirations breathing and coughing secretion without
 Cough cough,
not be noiseless, technique causing Coughing is minimized
 Respiratory bronchopulm
ventilated improved breathlessness and
rate= 23 onary
because of oxygen fatigue. Identifies signs of early
Cpm infection
secretion and exchange infection
 Use of mucosal edema  Demonstrate Bronchial irritants
accessory that can cause Instruct patient to avoid cause
behavior to
muscle partial bronchial irritant such bronchoconstriction
improve or
occlusion of the maintain clear as cigarette smoking, and increased mucus
bronchi, with a airway. aerosol and extreme production, which
resultant temperature then interferes with
decrease in airway clearance
alveolar oxygen
tension. Provide rest period Conserve energy and
lessen fatigue

Dependent:
Administer antibiotic as Antibiotic may be
prescribed prescribed to prevent
or treat infection

Administered oxygen Promotes individual

therapy at 2 Lpm learning

Collaborative:

Discuss with the SO

ways in reducing cross
contamination or
infection in the family.
Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Analysis
Subjective: Ineffective The presence of That after nursing Independent After nursing
(no verbal cerebral tissue partial blockage of interventions, the interventions the patient
output) perfusion the blood vessel patient will be able to: -Closely assess and -Assesses trends in was able to:
related to can be monitor neurological level of consciousness
Objective: interruption of multifactorial. -demonstrate increase status frequently and (LOC) and potential for -Maintained motor,
-Right sided blood flow These can be due perfusion as compare with increased ICP and is sensory, intellectual and
weakness secondary to to individually baseline. useful in determining language changes
CVA vasoconstriction, appropriate location, extent, and minimally
-Changes in platelet adherence progression of damage. (partially met)
motor, on rough surface, -Display no further May also reveal
sensory, fat accumulation deterioration/recurren presence of TIA, which Patient exhibit a little
intellectual and therefore ce of deficits may warn of impending improvement especially
and language decreases thrombotic CVA. on the stimulation to the
elasticity of vessel patient upon rounds
-With the ff. wall blood -Position with head -Reduces arterial
v/s of perfusion with the slightly elevated and pressure by promoting -Displayed no signs of
BP initiation of the in neutral position venous drainage and serious complications
160/100 clotting sequence. may improve cerebral (partially met)
mmHg This may be later perfusion. During the span of care,
PR 85BPM lead to the the patient did not
RR 23 development of Dependent: manifest serious
CPM thrombus which -Administration of -May be used to communication
CRT 3 can be loosened aspirin (anti platelet improve cerebral blood
SEC and dislodged in aggregator) flow and prevent further
some areas of the clotting when embolism
brain such as mid and/or thrombosis the
cerebral carotid problem.
artery that may
lead to alteration -Administration of -These agents are
of blood perfusion Citicholine 500mg ( being researched as a
leading into CVA. CNS stimulant; means to protect the
Source: neuroprotective brain by interrupting the
Nurses pocket agent) destructive cascade of
guide biochemical events
Doengers (influx of calcium into
Moorhouse cells, release of
Geissler-Murr excitatory
Pg. 537, 544 neurotransmitters,
buildup of lactic acid) to
limit ischemic injury.
 Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Analysis
Subjective: Ineffective Hypertension Short term After 8 hours of nursing
(no verbal output) tissue perfusion increases the Independent: intervention the patient
Objective Cues: related to workload of the That after 8 hours of -Positioned patient -Elevation of the head of was able to:
increased heart and nursing intervention to low-fowler’s bed improves lung
vascular increasing the the patient will be position expansion and facilitates -Exhibited slight
resistance oxygen demand able to: ventilation improvement of
-Capillary refill test and coronary capillary refill of 3
of 2-4 seconds blood flow -Exhibit improved -Assessed and -For baseline data and to seconds.
causing circulation as monitored vital monitor for changes in the (Partially Met)
-Blood pressure of vasoconstriction manifested by a signs noting high or vital signs
160/100 mmHg of the capillary refill of less low blood pressure, -Manifested blood
peripheral than 3 seconds rapid heartbeat, pressure within normal
tissue. (Kozier rapid respirations, range of 140/80 mmHg.
and Erb’s) -Manifest BP within warm or cold (Met)
fundamental of normal range temperature
nursing pg.
1295) -Noted current -to provide the appropriate Expected Outcome:
Long term goal: condition or management needed After 7 days of nursing
situation of the intervention the:
That after 7 days of patient that can
nursing intervention, affect perfusion to -S.O. will demonstrate
the patient will be all parts of the body willingness and
able to: behavior in complying
-Monitored intake -to monitor for signs of the patient’s
-Comply in taking his and output fluid loss and fluid gain. maintenance
maintenance medication
medications through
the significant other’s -Promoted -to conserve energy -S.O. will be able to
help adequate rest follow the dietary
regimen of the patient
- follow dietary -Provide the -for the S.O. to be aware as prescribed.
regimen as significant other on what needs to be done
prescribed through health teachings in order to manage
the help of the about the patient’s condition
significant other condition, its
causes and
treatments which
includes
maintenance
medications and
lifestyle
modifications
needed

-Administered -To provide adequate

oxygen therapy at 2 oxygenation of the body
Lpm

Dependent:
-Continued IVF -To balance fluid intake.
therapy with PNSS i
L at 10 gtts/min

-Administered -to decrease the blood

Losartan 50mg pressure and promote
once a day as vasodilation of the blood
prescribed vessels.

Collaborative:
-On Coumadin -To provide continuous
(diet) blenderized nutrition of the patient
feeding 1500kcal in
1000 ml in 6 divided
feeding.
 Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Analysis
Subjected cues: Ineffective . Body defense That after 30 mins- 1 Independent: After 30 mins-1 hour of
none thermoregul mechanism is hour the patient will be nursing intervention, the
ation related to increase the able to: -Provide tepid sponge -To promote body patient was able to
Objective cues: to increase thermoregulatio bath cooling
-Temperature= body n of the SHORT TERM -Attain normal
38.3C temperature hypothalamus, -Have a decrease -Monitor client -Serves as a temperature
releasing the Temperature from temperature, note baseline data and (met)
pyrogens 38.3C to the normal shaking/chills noted for any
increasing the range of 36.5-37.5C changes in the -Patient had a
body temperature temperature of 36.5C
temperature to and was able to maintain
remove -Monitor environmental -Room temperature the expected normal
invading temperature and the number of temperature through the
bacteria or blankets should be care
pathogen altered to maintain
Source: near normal body
Nurses pocket temperature
guide Dependent:
Doengers
Moorhouse -Administer paracetamol -Use to reduce fever
 Geissler-Murr 500mg/tablet as ordered by its central action
Pg. 287-290 on the hypothalamus

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Analysis
Subjective: ( no Impaired verbal It is caused by That after nursing Independent: After nursing
verbal output) communication lack of blood interventions the interventions the
related to supply which is patient will be able -Provide an -Impaired ability to patient was able to :
Objective: impaired then surrounded to: atmosphere of communicate
-Slurred speech cerebral by an area of cells acceptance and spontaneously is -Established
circulation as that are -Establish privacy by speaking frustrating and communication in
evidenced by secondarily communication in slowly and in embarrassing. Nursing which needs of the
slurred speech affected since the which needs can normal tone, not action should focus on patient was answered.
symptoms be expressed non forcing the patient decreasing the tension (partially met)
depend on the verbal cues) to communicate and conveying an
location of the understanding -The patient was not
stroke and the totally expressive in his
size of the infarct, -Taught techniques -As the client’s speech needs but can be
it could involve to improve speech improves, his confidence assessed through
the brain’s by initially asking increases and he will more observation to the
brocca’s area question attempt to make speech. patient’s facial
which is primary answerable by yes expression
responsible for or no
communication
through facial Collaborative:
expression and
speech by -Involved SO in the -Enhances participation
causing damage plan of care and commitment to plan.
to this area, the
patient’s -Educate relatives -Imparts thoughts and
communicating to establish a answers the needs of the
skills may be method of patient
altered and communication
affected. through sign
Source: language
Nurses pocket
guide
Doengers
Moorhouse
Geissler-Murr
Pg. 135, 139
Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Analysis
Subjective: Impaired Stroke in which Long Term goal: Independent: After nursing
(no verbal physical nerve cells in the That after nursing interventions the
output) mobility related brain die for lack interventions the patient will -Change positions at -Reduces risk of tissue patient was able to:
to of oxygen can be able to: least every 2 hr injury. Affected side has
Objective: neuromuscular result in -Maintain/increase (supine, side lying) poorer circulation and Maintained the
- right sided involvement permanent strength and function of and possibly more reduced sensation and strength and function
weakness secondary to disability for the affected or compensatory often if placed on is more predisposed to of the affected body
-unable to CVA patient, because body part affected side skin breakdown part. Muscle strength,
perform ADL of the pathway 5 for left upper and 4
-limited ROM transmit -Maintain skin integrity -assess affected -to evaluate the current lower extremities and
information in the side for color, status of the affected 1 for right upper and
brain are -Maintain optimal position edema, or other area lower extremities.
interrupted. The of function as evidenced by signs of (partially met)
symptoms often absence of contractures, compromised
primarily affect foot drop. circulation -Maintained optimal
one side of the position of function
body because -Inspect skin -Pressure points over with no evidence of
blood flow is cut regularly, particularly bony prominences are contractures and foot
off to part of the over bony most at risk for drop.
brain. prominences. decreased perfusion. (partially met)
 Source:
Nurses pocket -Assist patient with -Minimizes muscle
guide exercise and atrophy, promotes
Doengers perform ROM circulation, and helps
Moorhouse exercises for both prevent contractures.
Geissler-Murr the affected and
Pg. 333-337 unaffected sides.

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Analysis
Subjected cues: Activity Motor deficits That after nursing Independent: After nursing
none Intolerance are the most interventions the interventions the patient
related right obvious effect patient will be able to: -Assess changes in -To note progress in was able to:
Objective cues: sided of stroke. cardiopulmonary fatigue or weakness
-Right sided weakness Symptoms are -Demonstrate a response to physical -Demonstrate a
weakness noted secondary to caused by the measurable increase in activity and changes in measurable increase in
CVA destruction of tolerance to activity BP activity
-Muscle strength, motor neurons (partially met)
5 for left upper in the pyramidal That after nursing -Assist patient in activity -To protect patient in -Patient was able to
and 4 lower pathways interventions the acquiring injury tolerance positioning,
extremities and 1 (nerve fibers in significant others will morning care without
for right upper the brain be able to: -Plan care in between -To decrease fatigue signs of respiratory
and lower passing through periods to provide and further distress
extremities. the spinal cord -Identify techniques to adequate rest period weakness
-unable to to motor tract) improve activity -Indentified techniques
perform activities intolerance -Provide an environment -Reduces stress and to improve activity
of daily living. Source: and limit visitors excess stimulation, intolerance
Nurses pocket -Demonstrate and promoting rest (met)
guide verbalize ways to S.O was able to
Doengers increase supply and -Explain importance of -This is to decreased determine activities
Moorhouse decrease demand of rest in treatment plan and metabolic demands appropriate to the
Geissler-Murr oxygen necessity for balancing thus, conserving patient to conserve
Pg. 60-63 activities with rest energy for healing energy consumption.

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Analysis
Objective: Self-care Most of the Independent After 4 hours of
deficit related patients having Short term: -Assess abilities and level -Aids in nursing intervention
- unable to to post-stroke state -Identify individual of deficit for performing anticipating/planning the patient and
comb hair neuromuscula often have areas of ADLs. for meeting individual significant others
 r impairment. unilateral weakness/needs. needs was able to :
-inability to sit impairment of
upright neuromuscular -Demonstrate -Avoid doing things for -These clients may For SO:
function. This techniques/lifestyle client can do for self, become fearful and -understand the
-patient was impairment often changes to meet self- providing assistance as dependent, and importance of
unable wipe leads to impaired care needs. necessary. although assistance is maintaining proper
face and unable self-care abilities helpful in preventing hygiene,
to change since movement Long term: frustration, it is (met)
clothing and even Perform self-care important for client to
ambulation is activities within level do as much as -demonstrate
difficult and of own ability.  Be aware of impulsive possible for self to behavioral changes
-inability to sometimes behavior/ actions maintain self-esteem that promote self
perform self- impossible suggestive of impaired and promote recovery care management to
feeding (Smeltzer, 2010). judgement. (Doenges, 2006). the patient.
 Client needs (met)
-inability to empathy and to know
perform oral and  Provide positive caregivers will be The significant
personal feedback for efforts and consistent in their others was aboe to:
hygiene. accomplishments. assistance. Demonstrate
(Doenges, 2006) techniques to meet
self care needs such
 Enhances sense of as:
 Encourage SO to allow self-worth, promotes Utilizing unaffected
client to do as much as independence, and side of the body in
possible. encourages client to performing self-care
continue endeavors. Requesting S.O. to
(Doenges, 2006) assist in performing
self-care
 Assists in (met)
 Create plan for visual development of
deficits that are present retraining program

COLLABORATIVE

 Consult with  Provides assistance

rehabilitation team/ in developing a
physical/ occupational comprehensive
therapists. therapy program and
identifying special
equipment needs
that can increase
client’s participation
in self-care.
(Doenges, 2006)
 Assessment Nursing Scientific Analysis Planning Intervention Rationale Evaluation
Diagnosis
Subjective: ( no Risk for Disorders affecting That after Independent: After nursing
verbal output) Aspiration the oral preparatory nursing interventions the
Related to and oral propulsive interventions, the -Assess gastrointestinal -to rule out patient was able to:
Objective: Reduced level phases usually result patient will be function hypoactive
-Neuromuscular of from impaired control able to: peristalsis and -Displayed no signs of
dysfunction consciousness of the tongue, abdominal serious complications
-GCS=9 Secondary to although dental - -Display no brought about by the
(E=4,V=1,M=4) CVA problems may also be further -Position patient with -Degrees to prevent NGT
involved. When eating deterioration/rec head of bed elevated 45 gastric reflux ( met)
-decreased solid food, patients urrence of degrees through gravity.
swallowing may have difficulty deficits -prevent any injury that
reflex chewing and initiating -To prevent can lead patient to
swallows. When -Shows -Provide frequent and colonization of the aspirate.
-NGT on left drinking a liquid, improvement in scrupulous mouth care oropharynx with (met)
nares patients may find it his GCS bacteria and
difficult to contain the monitoring inoculation of the
liquid in the oral cavity lower airways.
before they swallow.
As a result, liquid -Check placement of -To ensure proper
spills prematurely into feeding tube either by placement of the
the unprepared auscultation or tube.
pharynx, and this radiographically at
often results in regular intervals (e.g.,
aspiration. With before administering
dysfunction of the intermittent feedings and
pharyngeal phase of after position changes,
swallowing, food suctioning, coughing
transport to the episodes, or vomiting)
esophagus may be
impaired. As a result,
food is retained in the
pharynx after a
swallow.
Source:
Nurses pocket guide
Doengers Moorhouse
Geissler-Murr
Pg. 86-89
 Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Analysis
Subjective: Risk for Loss of balance Short term: INDEPENDENT The patient/SO was
no verbal output injury related and Verbalize able to :
to neuromuscular understanding of -Assess client’s muscle  To identify risk for -Demonstrated
Objective: generalized impairment, and individual factors that strength, gross and fine fall. (Doenges, behaviors that
weakness. dizziness also contribute to motor coordination. 2009). reduces risk for
-Loss of balance contributes to possibility of injury. injury such as :
-Neuromuscular injury risk since Demonstrate -Assess mood, coping  May result in
impairment patient have the behaviors, lifestyle abilities, personality styles carelessness/increas -Scanning unto
-right sided tendency to fall changes to reduce (e.g., temperament, ed risk-taking without surroundings before
weakness anytime risk factors and aggression, impulsive consideration of attempting to move
(Fishbasch, protect patient from behavior, level of self- consequences. to reduce injury
2009). Inability to injury. esteem). (Doenges, 2009).
have a full visual Modify environment
field due to ptosis as indicated to
induces a risk of enhance safety -Preferable request
injury since -Perform thorough  Failure to accurately for adequate lighting
reception of visual Long term: assessments regarding assess and intervene in the room to
field is impaired. Patient will be free safety issues when or refer these issues clearly visualize the
Loss of balance from injury planning for client care can place the client surrounding to avoid
and and /or preparing for needless risk and injuries
neuromuscular discharge from care. creates negligence
impairment, and issues for the -Request for raising
dizziness also healthcare side rails in the bed
contributes to practitioner. to provide safety
injury risk since (Doenges, 2009)
patient have the -Request for
tendency to fall -Ascertain knowledge of  To prevent injury. assistance to care
anytime safety needs/injury (Doenges, 2009) provider upon
(Fishbasch, prevention and motivation turning patient side
2009). to side
Maintain bed/ chair in  To promote client
lowest position with safety. (Doenges,
wheels locked. 2009)

Discuss importance of  May contribute to

self- monitoring of occurrence of injury
conditions/ emotions. (e.g., fatigue anger,
irritability). (Doenges,
2009)

Identify interventions/  To promote safe

safety devices. physical
environment and
individual safety.
(Doenges, 2009)