NCP CVD

ASSESSMENTNURSING

DIAGNOSISPLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

Subjective“Masakit yung opera sa

akin”

Objective Facial Grimace Guarding behaviour over incision site

BP=130/90mmHg PR=70 bpm regular and equal in strength bilaterally RR=20 cpm regular and bilateral equal chest expansion Temp=35.8 C

Acute pain r/t post-operative

surgical incision secondary to

parotidectomy

Short Term Objective:

Within the shift, the pt will verbalize

decrease of pain felt in incision site

from 3/10 to 2-1/10 scale.

Long Term Objective:

After 3-6 days of NI, pt will report diminished pain

with a scale of 0/10

Establish therapeutic relationship

Monitor v/s

Assess pt’s general condition

Monitor I&O

Encourage increase OFI to al least 2-3 liters per day

Arrange bed linens

Encourage and assist client to active and passive ROM

exercises

Encourage rest opportunities

Provided comfort measures and safety

Carefully wash and pat dry skin, including skinfold area. Use

hydration and moisturization on all at-risk surfaces.

To gain pt’ and SO’s trust and

cooperation

To obtain baseline data

To note for the etiology or

precipitating factors that can aggravate the

risk.To have a

baseline data regarding input

and output

To maintain hydration status

.

To prevent increase pressure

To maintain blood flow

To promote optimum level of

functioning

The pt shall have took actions regarding minimizing the risk

The pt shall have been free from risk.

Assist client in changing positions every two hours

Provided Health information regarding the occurring problem

Provided conducive environment for resting

Encourage client to have balanced diet especially with

increased intake of vitamin C and Protein.

Monitor and Regulate IVF as per doctor’s order

To let pt feel safe and comfortable

To maintain skin moisture

To prevent pressure ulcer

To lessen the pt’s feeling of anxiety

To promote rest and pt’s wellness

To promote adequate

nourishment.

For proper replacement of

fluid losses.

Assessment Nursing Dx RATIONALE Goals Intervention Rationale EvaluationOBJECTIVE

Difficulty in producing

speech (+) cough with

thick secretions

(+) left sided weakness, with limited ROM on

upper and lower

extremities Non-

ambulatory Bedridden for

10 days BP=120/90mmH

g PR=85 bpm

regular and equal in strength

bilaterally RR=20 cpm

regular and bilateral equal

chest expansion

Temp=38.3 C(Fever)

Impaired verbal

communication

related to loss of

oral muscletone control.

A CVD, which may be caused by, hemorrhage,

thrombus, embolism or

vasospasm, can result in a local

area of cell death, called infarct. It is

caused by a lack of blood supply which is then

surrounded by an area of cells that are secondarily affected. Since

symptoms depend on the location of the stroke and size of the infarct, it

could involve the brain’s Brocca’s area, which is

primary responsible for communication through facial

expressions and speech. By

causing damage to this area, the

patient’s communicating skills are greatly

After 2 hours of nursing interventions, the client will establish method of

communication in which needs can be

expressed.

As evidence by:

Established eye contact while

communicating with others

Used paper and pen to express

needs

>Monitored vital signs with

emphasis to BP.

>Provided an atmosphere of

acceptance and privacy through speaking slowly and in a normal tone, not forcing

the client to communicate.

>Taught techniques to

improve speech by initially asking

questions that client can answer

with a “yes” or “no”.

>Used strategies to improve the

>Establishes baseline data for review of existing

conditions.

>Impaired ability to communicate spontaneously is frustrating and embarrassing.

Nursing actions should focus on decreasing the

tension and conveying an

understanding of how difficult the

situation must be for the client

>Deliberate actions can be

taken to improve speech. As the client’s speech improves, his

confidence will increase and she will make more

attempts at speaking.

>Improving the client’s

comprehension

After 2 hours of nursing intervention the goal was met the client

established method of communication in which needs are

expressedAs evidenced by :

Established eye contact while

communicating with others

Used paper and pen to express

needs

altered and affected.

(Medical- Surgical Nursing, vol.2,9th edition,

Brunner & Suddarths, page

1259 )

client’s comprehension by using touch and behavior to communicate calmness and

adding other non – verbal methods

of communication such as pointing

or using flash cards for basic needs; using

pantomime; or using paper and

pen.>Involved the

significant others in the plan of

care.

>Educated relatives to establish a method of

communication through sign

language.

can help to decrease

frustration and increase trust.

Clients with aphasia can

correctly interpret tone of voice.

>Enhances participation and commitment to

plan.

>Imparts thought and answers the

needs of the client with lessened difficulty.

(Nursing Care Plan, 6th edition, Gulanick/Myers

pg. 565)

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONALE

EXPECTED OUTCOME

S= 0

The patient manifested the

following:

O= with dysphagia, with reports of body

malaise, increased urine

output indwelling Foley catheter,

pallor, cold skin, physical

immobility.

Risk for Impaired skin integrity

The skin is the baseline defense of the body

against infection. Any break in the skin may

harbor microorganisms that may invade the

normal processing of the body, which may

inflict or aggravate the pt’s disease condition.

Short Term Objective:After 4 hr of

nursing intervention the pt will take actions

regarding minimizing the

risk


After 3 days of NI, pt will be free of

the risk.

Establish therapeutic relationship

Monitor v/s


Monitor I&O

Encourage increase OFI to al least 2-3 liters per

day

Arrange bed

To gain pt’ and SO’s trust and

cooperation



precipitating factors that can aggravate the

risk.To have a

baseline data regarding input

and output

To maintain hydration status

.

To prevent

The pt shall have took actions

regarding minimizing the risk

The pt shall have been free from risk.

linens

Encourage and assist client to

active and passive ROM

exercises

Encourage rest opportunities

Provided comfort measures and

safety

Carefully wash and pat dry skin, including skinfold

area. Use hydration and

moisturization on all at-risk surfaces.

Assist client in changing

positions every two hours

Provided Health information

regarding the occurring problem

Provided conducive

environment for

increase pressure

To maintain blood flow

To promote optimum level of

functioning

To let pt feel safe and comfortable

To maintain skin moisture

To prevent pressure ulcer

To lessen the pt’s feeling of anxiety

To promote rest and pt’s wellness

restingEncourage client to have balanced

diet especially with increased

intake of vitamin C and Protein.

Monitor and Regulate IVF as

per doctor’s order

To promote adequate

nourishment.

For proper replacement of

fluid losses.

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE Difficulty in

producing speech

(+) cough with thick

secretions (+) left sided

weakness, with limited ROM on upper and

lower extremities

Non-ambulatory

Bedridden for

Risk for Injury r/t altered mobility

secondary to CVD

Because of limited range of motion and

slightly paralyze body the patient is unable to mobilize properly which maybe a risk for injury.

Short Term Objective:After 2 hr of

nursing intervention the pt will demonstrate

behaviors, lifestyle changes

to reduce risk factors and

protect self from injury


>Establish rapport

>Monitor v/s

>Assess pt’s general condition

>Assess mood, coping abilities,

personality styles

>To gain pt’ and SO’s trust and

cooperation

>To obtain baseline data

>To note for the etiology or

precipitating factors that can lead to fever.

>that may result in carelessness

and increased risk


The patient shall have demonstrated behaviors, lifestyle changes to reduce

risk factors and protect self from

injury


The patient shall

10 days BP=120/90mm

Hg PR=85 bpm




chest expansion

Temp=38.3 C(Fever)

After 2 days of NI, pt will be free of

injury

>Identify interventions and

safety devices

>Encourage participation in

self-help programs, such

as assertiveness training, positive

self image

>raise the side rails of the bed

>Frequent skin inspection

>Use effective lighting

>Remind client to walk slowly

>Keep things into right premises

taking without considerations of

consequences

>To promote safe physical

environment and individual safety

>To enhance self esteem. sense of

worth

>To promote safe physical

environment and individual safety

> To assess if there is presence

of pressure ulcers.

>To promote safety and easy scanning of the environment.

>To prevent injury due to slipping, and to promote

safety.

>To prevent injury and promote

have been free of injury.

and clear the way going to the

restroom

safety.

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONPLANNING

INTERVENTIONS

RATIONALEEXPECTED OUTCOME

OBJECTIVE Difficulty in

producing speech

(+) cough with thick

secretions (+) left sided

weakness, with limited

ROM on upper and lower

extremities Non-

ambulatory Bedridden for

10 days BP=120/90mm

impaired verbal and/or written

communication r/t impaired

cerebral circulation

There is an affectation of the certain brain

lobes that caused by impaired cerebral

circulation that affects its proper functions that

leads to decreased, delayed or absent ability to receive,

process, transmit and use a system o

symbols in communicating

resulting in impaired verbal communication.


After 3 hrs of nsg int. the pt will be able to verbalize

or indicate understanding of

the communication

difficulty and plans for ways of

handling.


After 3 days of nursing

Establish rapport

Monitor v/s


Note results of neurological

testing such as EEG/CTscan and

the likes

To gain pt’s therapeutic relationship



precipitating factors that can lead to fever.

To assess causative/contrib

uting factors


After the nrsing intervention the pt shall verbalize ir

indicate understanding of communication

difficulty and plans for ways of handling


After the nursing intervention the pt

Hg PR=85 bpm




chest expansion

Temp=38.3 C(Fever)

intervention the pt will establish

method of communication in which needs can

be expressed.

Assess environment

factors that may affect ability to communicate

Establish relationship with

the client , listening carefully and attending to

clients verbal/nonverbal

expressions

Maintain a calm, unhurried

manner, provide sufficient time for

the client to responds

Anticipate needs until effective

communication is reestablished

Administer due meds

To assess causative/contrib

uting factors

To assist client to establish a means of

communication to express needs,

wants, ideas and questions

Individuals may talk more easily when they are

rested and relaxed

To attend pt’s needs

immediately

For pt’s recovery and to treat underlying conditions

shall be albe to establish methods of communication in which can be

expressed.

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING INTERVENTIONS

RATIONALE EXPECTED OUTCOME

S= 0

The patient

Impaired Physical Mobility

R/t

The nervous system is made up of nerve cells

called neurons that


After 4 hrs. Of

>Establish Rapport

> To gain pt’s therapeutic relationship


After 4 hrs. Of

manifested the following:

O= w/ pale palpebral

conjunctiva, w/ pale nail beds, w/

capillary refill time, <3sec. pt. is able to feel deep touch, raise his

right arm and leg, w/ slurred

speech, w/ left sided weakness, with limited ROM

on upper and lower extremities, afebrile, (-) DOB,

(-) chest pain.

The patient may also manifest he

following:

>Slowed movement,>Postural

instability during performance of

ADLs>Movement

induced shortness of

breath.

neuromuscular involvement secondary to CVA infarct

.

serve as the communication system of the body. They carry messages in the form of electrical impulses. The messages move from one neuron to another to keep the body functioning.

Because neurons have, limited ability to repair

themselves unlike other body tissues that is why

nerve cells cannot be repaired if damaged

due to injury or disease.

Nursing Intervention, the pt. will be able

to maintain increased

strength and function of affected or

compensatory part.


After 2-3 days of nursing

intervention, the pt. will be able to demonstrate behaviors that

enable resumption of

activities.

>Monitor Vital signs

>Assess patient condition

>Provide adequate rest periods as well as comfort &

safety measures

>Turn pt. slowly from side to side

>Determine pt. level of mobility

>Assist pt. in his activities

>Encourage adequate intake

of fluids & Nutritious foods

>Involve client’sSO in care

> To identify any other deviations

from normal.>To determine

any other underlying cause of manifestations

> To prevent further stress &

fatigue

> To provide proper circulation of blood flow on

both sides

>To assess functional ability

>To promote optimal level of

function

>Promotes well-being and maximizes

energy production.

>To assist in learning ways of

managing problems of immobility.

Nursing Intervention, the

pt. shall be able to maintain

increased strength and function of affected or

compensatory part.


After 2-3 days of nursing

intervention, the pt. shall be able to

demonstrate behaviors that

enable resumption of

activities.

Documents

NCP CVD