NANDA Nursing Diagnosis: _____Impaired physical mobility____ Related to: altered muscular function secondary to cerebral injury
As evidenced by (only use if not “risk for”) weakness on his left side and unsteady gait
PLANNING PHASE IMPLEMENTATION PHASE RATIONALE EVALUATION PHASE
Patient-centered goal (s) Interventions: Must be written in order of priority. Use a primary source to provide Goal/s met?
Be sure goal is measurable and Think about all the things the RN does to help the the rational for your specific
includes an appropriate time patient with this problem. Be specific. nursing intervention. Cite
frame. references.
Consider: Short term goal &
long term goal
1. Patient will do range of 1a. Nurse will educate patient to do the moves 1a and 1b. prevents muscle 1. Goal met – patient was able to
motion exercises as ordered by slowly and carefully and emphasize that patient degeneration, improves balance perform ROM exercises with
the physician during each shift shouldn’t force it if he can’t do a certain exercise and strength minimal assistance during shift
1b. Nurse will assist patient with range of motion 2a. reduces the risk of pressure
exercises but let the patient do some of the ulcers and injuries due to improper
exercises independently if he can. alignment (Allina Health, n.d.)
2. Patient will ambulate with 2a. Nurse will reposition the patient every 2 hours 2b. reduces risk of falling and the 2. Goal met — patient was able to
assistance as ordered by the position the patient in proper alignment gait belt can guide the patient ambulate with a walker and gait
physician during each shift down belt held by the nurse during shift
2b. Nurse will assist the patient during ambulation
2c. evaluation will help the nurse
2c. Nurse will provide aids (walkers, canes, gait know if the plan of care is
belt) for the patient as needed during appropriate for the patient
2d. Nurse will observe and document patient’s 2d. pain is the 5th vital sign and
ability to ambulate throughout his length of stay it’s a priority when it comes to
(Balderrama and Pravikoff, 2018) improving the patient’s quality of
life
2e. Nurse will assess pain if/when patient exhibits
signs and symptoms of pain during ambulation
,NANDA Nursing Diagnosis: Impaired Swallowing Related to: mild dysphagia secondary to stroke
As evidenced by (only use if not “risk for”): patient was coughing when eating/drinking
PLANNING PHASE IMPLEMENTATION PHASE RATIONALE EVALUATION PHASE
1. Patient will verbalize the 1a. Nurse will assess s/s of impaired swallowing 1a. Assessing the cause, signs, 1. Goal met — patient was able to
improvement of swallowing as and its cause and symptoms will allow the nurse verbalize that he can swallow
evidenced by absence of to know how to care for the patient food and liquids during
coughing when eating/drinking 1b. Nurse will elevate HOB during meals and and communicate clearly to the mealtimes.
(Balderrama and Pravikoff, 30-45 minutes after (Balderrama and Pravikoff, provider about the patient’s
2016). 2016). condition
1c. Nurse will provide 30 minutes of rest before 1b and 1c. This will minimize risk of
meals (Balderrama and Pravikoff, 2016). choking and aspiration
1d. Nurse will refer patient to speech therapist to 1d. This is outside of the nurse’s
perform a swallow study realm of expertise, speech
therapists are more well equipped 2. Goal met — patient was able to
2. Patient will verbalize the 2a. Nurse will educate the patient about the in doing a swallow study verbalize techniques taught by the
nurse’s teaching on ways to importance of alternating liquids and solids nurse during mealtimes
minimize risks of choking and (Balderrama and Pravikoff, 2016). 2a and 2b. This will help the patient
aspiration during mealtimes to swallow and learn how to adapt
2b. Nurse will educate the patient on certain foods to their current condition
that require minimal effort to consume and easy to
swallow (Balderrama and Pravikoff, 2016).
,NANDA Nursing Diagnosis: Altered Tissue Perfusion (Cerebral) Related to: Cerebrovascular accident
As evidenced by (only use if not “risk for”) decreased left hand grasp, asymmetry when the patient smiles, unsteady legs
PLANNING PHASE IMPLEMENTATION PHASE RATIONALE EVALUATION PHASE
1. Patient maintain adequate 1a. Nurse will perform a neurological assessment 1a and 1b. Assessing the cause, 1. Goal partially met — patient is
cerebral tissue perfusion as and vital signs every 4 hours. Assess s/s for signs, and symptoms will allow the currently still weak on his left side.
evidence by increased decreased cerebral tissue perfusion (Balderrama nurse to know how to care for the Patient was able to verbalize signs
movement of left side and and Pravikoff, 2018). patient and communicate clearly to of decreased tissue perfusion and
symmetry in face by discharge the provider about the patient’s stress-reducing techniques helps
(Balderrama and Pravikoff, 1b. Nurse will contact the provider if the patient’s condition lessen his anxiety
2018). s/s worsens or continues
1c. reduces the effects on stress
1c. Nurse will perform stress-reducing techniques which can worsen the patient’s
such AIDET, quiet environment, relaxation condition or patient can develop
techniques etc (Balderrama and Pravikoff, 2018). stress-related illnesses in the body
1d. Nurse will educate the patient signs of 1d. early detection of these signs
decreased tissue perfusion such changes in will help the physician develop the
vision, level of consciousness, and motor function appropriate treatment for the
(Balderrama and Pravikoff, 2018). patient
, N206: Head to Toe Assessment
Patient Initials: V.R Room # Neurological unit 0800
Most Recent Diagnosis: stroke mild left hemiplegia
Time of Assessment: 0800
Vitals IV Medications Due 5Ps
0800 1200 Site #1: 0730 0800 0830 0900
Date Inserted: 3/23 0930 1000 1030 1100 pain,
BP: 134/80 BP: 135/82 Location: RH 1130 1200 1230 1300 positioning,
RR: 12 RR: 12 personal items,
Solution/Rate: 100 ml/hr of Medication Rights: 1Patient,
SpO2: 96 SpO2: 97 personal needs,
NS 2Med, 3dose, 4route, 5time,
Temp:99 Temp: 99 privacy.
Site Assessment: 6rationale (7based on the right
HR: 100 HR: 95
✓ Clear □Redness assessment data),
□Pain □Warmth 8documentation, 9reaction.
□Swelling □Drainage Reminder: 10educate your
Site patency for a lock patient and they have a 11right
to refuse!
device: ___________
Labs Blood Glucose
Site #2:
8.1 Date Inserted: 0800 value: 94 mg/dl
13 Correction dose:!type of insulin_____units ______
Location: ____________
Meal Dose: !type of insulin_____units_______
Solution/Rate:_________ Should the meal dose be held? If so, why?
Site Assessment:
___________
□Clear □Redness □Pain ___________________________________________
□Warmth □Swelling __
□Drainage Percentage of meal eaten _______%
44
200 Site patency for a lock
1200 value: 91 mg/dl
device: ___________
142 96 18 Correction dose:!type of insulin_____units ______
Meal Dose: !type of insulin_____units_______
Should the meal dose be held? If so, why?
___________
