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ASSESSMENT DIAGNOSIS

GOAL/DESIRED OUTCOME

PLANNING
INTERVENTION Independent: " Assess functional ability/extent of impairment initially and on a regular basis. " Provide passive exercise to the affected area and active exercise to unaffected area like quadriceps drills such as flexion, extension, abduction, adduction etc. " Assist to develop sitting balance (raise head of bed; assist to sit on edge of bed, having patient use the strong arm to support body weight and strong leg to move affected leg). " Assess patient to ambulate. " Provide safety measure such as placing necessary things within the reach of the patient. RATIONALE

IMPLEMENTATION EVALUATION

Subjective: Di ako makahiwag maayo as verbalized by the patient.

Objective: " Left hemiplegia " Weakness

Impaired physical mobility related to neuromuscular impairment as manifested by di ako makahiwag maayo as verbalized by the patient, left hemiplegia and weakness.

Within 1 hour of nursing intervention, the patient will be able to demonstrate techniques/ behaviors that enable resumption of activities.

" Identifies strengths/deficiencies and may provide information regarding recovery. " Minimizes muscle atrophy, promotes circulation and helps prevent contractures.

" Aids in retaining neuronal pathways, enhancing proprioception and motor response.

" To prevent deformities or contractures. " To prevent from any accidents. " To poster independence.

Assessed functional ability/extent of impairment initially and on a regular basis. Provided passive exercise to the affected area and active exercise to unaffected area like quadriceps drills such as flexion, extension, abduction, adduction etc. Assisted to develop sitting balance (raise head of bed; assist to sit on edge of bed, having patient use the strong arm to support body weight and strong leg to move affected leg). Assess patient to ambulate. Place necessary things within the reach of the patient.

Goal met; After 1 hour of nursing intervention, the patient wasable to demonstrate techniques/ behaviors that enable resumption of activities.

ASSESSMENT

DIAGNOSIS
GOAL/DESIRED OUTCOME

PLANNING
INTERVENTION RATIONALE

IMPLEMENTATION
Provided alternative methods of communication like pictures or visual cues, gestures or demonstrations. Anticipated and provided for patients needs.
Helpful in decreasing frustration when dependent on others and unable to communicate desires. It reduces confusion or anxiety and having to process and respond to large amount of information at one time. Patient is not necessary patient impaired and raising voice may irritate or anger the patient. It is important for family members to continue talking to the patient to reduce patients isolation, promote establishment of effective communication and maintain sense of connectedness or bonding with the family. " To improve the speech articulation.

EVALUATION

Subjective: Lisod ako mag-istorya as verbalized by the patient in a low sound and unclearly way. Objective: Right facial paralysis Speaks or verbalizes with difficulty

Impaired verbal communication related to loss of oral muscle tone control as manifested by lisod ako magistorya as verbalized by the patient in a low sound and unclearly way, right facial paralysis, speaks or verbalizes with difficulty.

Within 1 hour of Independent: Provide alternative nursing methods of intervention, the communication like patient will pictures or visual cues, establish method gestures or demonstrations. of Anticipate and provide communication for patients needs. in which needs can be expressed.
Talk directly to patient. Speaking slowly and directly. Use yes or no questions to begin with. Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Encourage family members and visitors to persist efforts to communicate with the patient.

Provide communication needs or desires based on individual situation or underlying deficit.

Talked directly to patient. Speaking slowly and directly. Use yes or no questions to begin with. Spoke in normal tones and avoided talking too fast. We gave patient ample time to respond. Encouraged family members and visitors to persist efforts to communicate with the patient. Instructed patient for speech exercises such as bubble gum chewing, oral reading etc. Administered Citicoline (oral drops 2cc TID) and Piracetam (800mg OD).

Goal met; After 1 hour of nursing intervention, the patient was able to establish method of communication in which needs can be expressed.

Instruct patient for speech exercises such as bubble gum chewing, oral reading etc. Collaborative: Administer Citicoline (oral drops 2cc TID) and Piracetam (800mg OD).
"

Citicoline-ACE inhibitors or antihypertensive Piracetam-enhance cognitive functions, including memory and attention.

ASSESSMENT DIAGNOSIS
GOAL/DESIRED OUTCOME

PLANNING
INTERVENTION RATIONALE

IMPLEMENTATION EVALUATION

Independent: " Establish rapport. Subjective: (none) " Monitor vital signs.

" To promote cooperation. " To have a baseline data.

Established rapport. Vital signs were monitored. Kept the chairs and

Goal met; After30

Objective: " Left hemiplegia

Risk for injury related to right hemiplegia secondary to CVA

Within 30 minutes of nursing intervention, the patient will be able to seek help to perform tasks that are beyond his capabilities.

" Keep the chairs and " To protect from pillows at the side falling out of bed. of the bed. " Remind patient to " To prevent injury. walk slowly, rest adequately between intervals of walking use effective lighting. " Inform patients SO " For continuous monitoring and not to leave him in the bathroom. guidance for the patient.

pillows at the side of the bed. Reminded patient to walk slowly, rest adequately between intervals of walking use effective lighting. Informed patients SO not to leave him in the bathroom.

minutes of nursing intervention, the patient sought help to perform tasks that are beyond his capabilities.

ASSESSMENT DIAGNOSIS
GOAL/DESIRED OUTCOME

PLANNING
INTERVENTION RATIONALE

IMPLEMENTATION EVALUATION

Subjective: Hadlok ako san phlebotomy kag di ko aram ini na sakit koas verbalized by the patient.

Objective: " Worried facial expression

Deficient Knowledge related to unfamiliarity with information resources as manifested by hadlok ako san phlebotomy kag di ko aram ini na sakit ko as verbalized by the patient and worried facial expression.

Independent: " Evaluate type/degree of sensory-perceptual involvement. Within 30 minutes of nursing intervention, the patient will be able to verbalize understanding of condition/ disease process and treatment. " Include SO in discussions and teaching.

" Discuss specific pathology, cause and managements.

" Deficits affect the choice of teaching methods and content or complexity of instruction. " These individuals will be providing support or care and have great impact on clients quality of life. " Aids in establishing realistic expectations and promotes understanding of current situation and needs. " Minimize residual deficits

Evaluated type/degree of sensory-perceptual involvement. Included SO in discussions and teaching. Discussed specific pathology, cause and managements. Reinforced importance of followup care.

Goal met; After 30 minutes of nursing intervention, the patient was able to verbalize understanding of condition/ disease process and treatment.

" Reinforce importance of follow-up care.

ASSESSMENT DIAGNOSIS
GOAL/DESIRED OUTCOME

PLANNING
INTERVENTION RATIONALE
Independent: " Discuss the cause of the problem and interventions. " Assist patient with the head support and position based on specific dysfunction. Within 1 hour of " Stimulate lips to close or nursing manually open mouth by intervention, the light pressure on lips or patient will be able under chin is needed. to verbalize " Feed slowly allowing 30understanding of 45mins. for meals.

IMPLEMENTATION

EVALUATION

" To provide information. " Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. " Aids in sensory retraining and promotes muscular control.

" Discussed the cause of the


problem and interventions.

Subjective: Lisod ako magtulon as verbalized by the patient.

Objective: " Incomplete lip closure

Impaired swallowing related to neuromuscular impairment (facial paralysis) manifested by lisod ako magtulon as verbalized by the patient, incomplete lip closure.

" Assisted patient with the head "


support and position based on specific dysfunction. Stimulated lips to close or manually open mouth by light pressure on lips or under chin is needed. Feed slowly allowed 30-45mins. for meals. Instructed to chew in the unaffected side. Provided consistency of food or fluid that is most easily swallowed. Massaged laryngopharyngeal musculature gently. Encouraged SO to bring favorite foods. Maintained upright position for 45-60mins. after meal. Remained to the patient after meal. Encouraged continuation of facial exercise.

"
" Feeling rushed can increase stress level of frustration may increase risk of aspiration and may result in clients terminating meal early. " To chew the food properly. " To avoid thicken oral secretions.

" " "


"

causative factors, identify interventions to " Instruct to chew in the unaffected side. promote intake and " Provide consistency of prevent aspiration food or fluid that is most and demonstrate easily swallowed. teaching methods. " Massage
laryngopharyngeal musculature gently. " Encourage SO to bring favorite foods.

" To stimulate swallowing.

" " "

Goal met; After 1 hour of nursing intervention, the patient was able to verbalize understanding of causative factors, identify interventions to promote intake and prevent aspiration and demonstrate teaching methods.

" Provide familiar tastes and preferences stimulates feeding efforts and may enhance swallowing or intake. " Maintain upright position " Helps patient manage oral secretions and reduces risk of for 45-60mins. after meal. regurgitation. " Remain to the patient after " To prevent anxiety. meal. " Encourage continuation of " To maintain or improve muscle facial exercise. strength.