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    Assessment Nursing Diagnosis Planning

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    Camille Ramos
    Provide physical assistance to the ➢ To prevent rebleeding and further However, due to severity of stroke, the patient as needed and as tolerated. Assist neurological impairment. patient still has paralysis on left side of with passive range of motion exercises, body and functional level of 4. Further transfers, ambulation, activities of daily rehabilitation is recommended. living.

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    Assessment Nursing Diagnosis Planning

    Uploaded by

    Camille Ramos
    187 views2 pages
    Provide physical assistance to the ➢ To prevent rebleeding and further However, due to severity of stroke, the patient as needed and as tolerated. Assist neurological impairment. patient still has paralysis on left side of with passive range of motion exercises, body and functional level of 4. Further transfers, ambulation, activities of daily rehabilitation is recommended. living.

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    NCP STROKE

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    Provide physical assistance to the ➢ To prevent rebleeding and further However, due to severity of stroke, the patient as needed and as tolerated. Assist neurological impairment. patient still has paralysis on left side of with passive range of motion exercises, body and functional level of 4. Further transfers, ambulation, activities of daily rehabilitation is recommended. living.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    187 views2 pages

    Assessment Nursing Diagnosis Planning

    Uploaded by

    Camille Ramos
    Provide physical assistance to the ➢ To prevent rebleeding and further However, due to severity of stroke, the patient as needed and as tolerated. Assist neurological impairment. patient still has paralysis on left side of with passive range of motion exercises, body and functional level of 4. Further transfers, ambulation, activities of daily rehabilitation is recommended. living.

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    ASSESSMENT NURSING DIAGNOSIS PLANNING

    Subjective Data: Problem Identified: Short-term objectives:


    ➢ “Dili na makalihok2 si mama sukad sya ➢ Hemorrhagic stroke caused by After 8 hours of nursing intervention the
    na stroke” as verbalize by the intracerebral hemorrhage significant other of the patient will:
    daughter of the patient. ➢ Verbalize understanding of the
    ➢ Nursing Diagnosis Statement: situation /risk factors, individual
    Objective Data: ➢ Impaired physical mobility related to therapeutic regimen and safety
    ➢ General body weakness Neuromuscular impairment measures.
    ➢ Tremors noted on left arm and hands ➢ Maintain position of function and
    ➢ Inability to perform gross/fin e motor Cause Analysis: skin integrity of the patient.
    skills Trauma (slipping) ➢ Demonstrate techniques/ behaviors
    ➢ Paralysis of left side of the body that will enable safe repositioning.
    ➢ Functional level scale: 4 (does not bone fracture at pelvic bone
    participate in activity ) Long-term objectives:
    Disruptions of periosteum and blood vessels After hospitalization, the patient will:
    ➢ Display improvement and increase
    Destruction if tissue strength and function in the affected
    body part.
    Bleeding occurs

    Pain

    Impaired bed mobility


    INTERVENTION RATIONALE EVALUATION
    Independent: Independent: Short-term objectives:
    ➢ Determine diagnoses that contribute ➢ To identify causative/ contributing Goals met. After 8 hours of nursing
    to immobility (e.g. fractures, factors. intervention the significant other of the
    hemi/para/tetra/q quadriplegia). patient was able to:
    ➢ Change positions at least every 2 ➢ To reduced risk for skin injury. An ➢ Verbalized understanding of the her
    hours. (Supine, side lying) and affected side has poor circulation and mother situation and explained the
    possibly more often if placed on reduced sensation. risk factors, individual therapeutic
    affected side. ➢ To reduce friction, maintain safe regimen and safety measures.
    ➢ Observe skin for reddened skin/tissue pressures and wick away ➢ Maintained position of function and
    areas/shearing. Provide appropriate moisture. skin integrity of the patient as
    pressure to relief. ➢ To prevent occurrence of injury evidenced by absence of
    ➢ Provide for safety measures including contractures, foot drop, decubitus.
    fall prevention. ➢ To promote wellness ➢ Demonstrate techniques/ behaviors
    ➢ Involve patient and SO in care that enable safe repositioning.
    assisting them to learn ways
    of managing problems of immobility. Long-term objectives:
    Dependent/Collaborative: Goals not met. After hospitalization, the
    Dependent/ Collaborative Used with caution in hemorrhagic disorder to patient:
    Administer medications as indicated by the prevent lysis of formed clots and subsequent Shall have improvement and increase
    physician; q.i.d antifibrinolytics rebleeding. strength and function of affected body part.

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