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Nursing Care Plan (CVA)

The nursing care plan is for a patient who suffered a cerebrovascular accident (CVA or stroke). The daughter reported that the patient was experiencing dizziness, headache, and weakness on one side of her body. On examination, the patient exhibited numbness on one side of her face, difficulty speaking, walking, and moving, loss of balance, and slow movement with limited range of motion. The short term goal was for the patient to participate in interventions and understand her condition, while the long term goal was to maintain or improve strength. The plan involved positioning, range of motion exercises, ambulation assistance, and administering prescribed medicines to address impaired physical mobility and promote recovery.

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Mel Rodolfo
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5K views2 pages

Nursing Care Plan (CVA)

The nursing care plan is for a patient who suffered a cerebrovascular accident (CVA or stroke). The daughter reported that the patient was experiencing dizziness, headache, and weakness on one side of her body. On examination, the patient exhibited numbness on one side of her face, difficulty speaking, walking, and moving, loss of balance, and slow movement with limited range of motion. The short term goal was for the patient to participate in interventions and understand her condition, while the long term goal was to maintain or improve strength. The plan involved positioning, range of motion exercises, ambulation assistance, and administering prescribed medicines to address impaired physical mobility and promote recovery.

Uploaded by

Mel Rodolfo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Nursing Care Plan - CVA

NURSING CARE PLAN - CVA

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Subjective:
Nahihilo tapos
sumasakit ang ulo
ni mama.
Nanghihina din
yung kalahating
parte ng katawan
nya. as verbalized
by the patients
daughter

Objective:
Numbness of the
face
Difficulty
speaking, walking
and moving
Loss of balance
Slow movement
limited range of
motion









Impaired physical
mobility related to
neuromuscular
impairment as
evidenced by
hemiparesis, loss
of balance and
coordination, and
limited range of
motion
Short Term:
After 8 hours of
nursing intervention,
patient will be able
to participate in the
activities and be able
to understand the
disease and her
condition

Long Term:
Maintain or improve
strength and
function of the
affected body part


Assess ability or
extent of immobility




Maintain proper
positioning

Place a pillow on the
affected part of the
body; pillow is also
placed under axilla to
abduct arm, elevate
hand and arm

Change position every
2 hours


Use footboard during
the period of flaccid
paralysis


Establish an exercise
program passive
range of motion
(both the affected
and unaffected part
To identify strengths
and weaknesses and
for comparative
baseline during
recovery

To prevent
contractures

To prevent pressure
ulcers; prevent
adduction of shoulder
and flexion of elbow



Promote venous
return and prevent
edema

Prevents contractures
and facilitates use
when/if function
returns

To maintain joint
mobility, regain
motor control,
prevent deterioration
of the neuromuscular
Short Term:
After 8 hours of
nursing intervention,
the patient verbalized
understanding of her
condition by her
gestures and was
able to participate in
the interventions give
to her. Goal met

Long Term:
Goal not met











of the body)


Give rest period to
activities


Provide positive
reinforcement during
activity




Assist to develop
balance. Encourage
and facilitate early
ambulation and other
ADLs when possible


Administer medicines
prescribed by the
doctor
system and enhance
circulation

Te help reduce
fatigue and oxygen
demand

Patients may be
reluctant to move or
initiate new activity
due to a fear of
falling; to boost their
confidence

The longer the
patient remains
immobile, the greater
the level of
debilitation that will
occur

Aids in training
neuronal pathways
enhancing motor
response


GROUP 2
BSN III-B

NURSING CARE PLAN - CVA ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective:  “Nahihilo tap
of the body) Give rest period to activities Provide positive reinforcement during activity

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