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NURSING CARE PLAN/NCP

Assessment Inference Diagnosis PIanning Intervention RationaIe EvaIuation



Subjective:

"Nahihirapan na
siyang ikilos ang
kanang bahagi ng
kanyang katawan
as verbalized by
the patient's wife.

Objective:

O Vital Signs:
BP: 160/100
Temp: 38.1C
PR: 145
RR: 12
O Slurred speech
O Body weakness
O Weak and pale
looking
O limited ability to
perform gross or
fine motor
movement
O Uncoordinated
or jerky
movements



Vasoconstriction


Blockage of the blood
vessels resulting to
embolism


Lack of oxygen and
nutrients supply resulting
to hypoxia


Altered cerebral
metabolism


| cerebral perfusion


Local acidosis


Cytotoxic edema


Aneurysm rupture


Stroke


Paralysis

mpaired
physical mobility
related to
damaged motor
neuronal
pathway.

After 4 hours of
nursing intervention,
the patient will be
able to gradually
restore physical
mobility as evidenced
by:

Verbalization of
understanding of
situation / risk
factors & individual
treatment regimen
& safety measures

Long Term:
Maintain or
increase strength
and function of
affected body part
or whole body.

Establish rapport with
the patient

Monitor Vital Signs



Reposition client q2



Provide safety
measures including
environmental
management

Encourage patient's
involvement in
activities & decision
making


Perform passive
range of motion
exercises daily


ncrease functional
activities as strength
improves

To gain patient's
trust

To obtain baseline
data and for
comparison

To prevent
development of
pressure ulcers

To reduce risk for
falls and further
injury


Enhances
commitment to plan
and optimizing
outcomes

To preserve muscle
strength and
functional ability

Limits fatigue and
ability to perform
ADLs.

Goal met

After 4 hours of
nursing
intervention, the
patient was able to
gradually restore
physical mobility as
evidenced by:


Verbalized
understanding of
situation / risk
factors & individual
treatment regimen
& safety measures

Maintain or
increased strength
and function of
affected body part
or whole body.