You are on page 1of 3

Nursing

Nursing
Assessment Rationale Goal Interventio Rationale Evaluation
Diagnosis
n

Subjective: Impaired CVA Short Term: Independent: Short Term:


“Hindi ko physical
magalaw mobility related After four hours Maintain Functional After four hours
yung to damage to Motor nerves are of nursing functional position prevents of nursing
kaliwang motor cortex or damaged interventions, alignment in contractures and interventions,
braso at binti motor pathways contractures and positioning the deformities that Contractures and
ko. pressure sores patient at rest. can further pressure sores
Namamanhid Left hemiplegia will be complicate are prevented as
pero pag prevented recovery and can evidenced by
may help reduce intact skin and
gumalaw, Impaired intracranial freely movable
masakit” physical pressure. joints.
mobility Goal Met
Support affected The weight of an
Objective: Long Term: arm when unsupported arm Long Term:
patient is out of may cause
Patient had After 8 hours of bed. shoulder After 8 hours of
Cerebrovascu nursing dislocation, joint nursing
lar accident interventions, inflammation, or interventions,
further both further
Left-sided complications of complications of
paralysis immobility will Provide passive To help maintain immobility were
be prevented. range-of-motion muscle tone and prevented as
exercise at least establish new evidenced by,
four times a day impulse intact skin,
pathways and maintained
neuron muscle tone, no
regeneration joint
inflammation or
Turn the patient Moisture dislocation, no
from side to side promotes contractures, and
at least every 2 bacterial growth maintained
hours. Keep and increases functional
bedding clean skin friability. alignment of the
and dry. Turning and extremities.
Massage bony massage help Goal Met
prominences. prevent pressure
Watch for sores from
fragile, thin, or developing and
excoriated skin, promote
which may shear circulation.
during turning.

Maintain Bladder training


adequate establishes
elimination. patterns and
Begin bladder bolsters the
training as soon patient’s
as possible confidence in
resuming
activities as
permitted.

Dependent:
Administer Citicoline
Citicoline as increases blood
ordered flow and oxygen
consumption in
the brain

You might also like