ASSESSME NT

DIAGNOS IS

SCIENTIFI C EXPLANAT ION

PLANNING

NURSING INTERVENTIONS

RATIONALE

EVALUATION

S>hindi ko magawang magayos dahil nanghihina ako O>ambulato ry w/ assistance >appers weak >inability to dress independentl y >v/s as follows: t=36.7c PR=100bpm RR=20=cpm BP=160/100 mmHg

self-care deficit related to right side body weakness secondary to left side CVA

After 4 hours of NI the pt will be able to demonstrate at least 2 self-care activities w/in level of own ability

Independent: >establish rapport >monitor vital signs >avoid doing things for client that client can do for self, providing assistance as necessary >maintain a supportive and firm attitude. Allow client sufficient time to accomplish tasks. >provide positive feedback for efforts and accomplishments.

Independent: >to build pt trust >to have a baseline data >it is important for the client to do as much as possible for self to maintain self-esteem and promote recovery

Goal met after 4 hours of NI the pt was able to perform 2 selcare activities w/in level of own ability

>client need empathy and to know caregivers will be consistent in their assistance

>enhance self worth, promote independence, and encourage client to continue endeavors >reestablish sense of independence and fosters self-worth and enhance rehabilitation process. >to promote blood circulation and prevent blood clots

>encourage SO to allow client to do as much as possible for self. >encourage client to perform ROM exercises

>identify previous bowel movement and reestablish normal regimen. Increase bulk in diet: encourage fluid intake, increase activity >place foods and utensils on the tray related to clients un affected side >Explain proper hair brushing and bathing to the patient Collaborative: >administer suppositories and stool softeners >consult w/ rehabilitation team/physical/occupati onal therapist

>to prevent constipation

>client will be able to see the food and will be able to reach food easily

>to provide correct pattern of performing the procedure

>maybe necessary to first aid in establishing normal bowel movement >provide assistance in developing a comprehensive therapy program and identifying special equipment needs that can increase client participation in selfcare.