Name of Student: Catherine B.

Jordan Section and Group Number: 3B, Group 3

Name of CI: Sarah Jane M. Rosales, RN MAN Area of Exposure: NEURO Ward

NURSING CARE PLAN

Pathophysiology /
Assessment Cues Nursing Diagnosis Desired Outcome Nursing Intervention Justification Evaluation
Schematic Diagram
Subjective Data: Impaired verbal Predisposing Factors: INDEPENDENT INTERVENTIONS:
The significant other communication  Advanced Age – 65 years After 8 hours of nursing After 8 hours of nursing
reported that the related to loss of old intervention, the patient will: 1. Assessed the extent of dysfunction: - Helps determine area and degree of intervention, the patient:
patient is having facial muscle tone  Elevated BP – 150/80 patient has trouble speaking (slurred brain involvement and difficulty
 Sex – Male (higher risk of 1. verbalize an understanding of
trouble speaking, as evidenced by
stroke
speech) patient has with any or all steps of the 1. verbalized an
“Nurse, ga-pukol slurring of speech.  History of HTN for
his communication problems. communication process. understanding of his
sya maghambal, indi almost 1 year communication problems.
namon ma  Episode of stroke – blood 2. establish method of 2. Asked the patient to follow simple - This is to test for receptive aphasia. Goal Met.
inchindihan”. clot resulted to O2 supply communication in which commands (such as “close and open
being cut off to the brain
needs can be expressed. your eyes,” “raise your hand”) and 2. established methods of
repeat simple words and sentences. communication in which
Objective Data: 3. use resources appropriately. needs can be expressed.
Definition: Precipitating
 Facial drooping 3. Listened for errors in conversation and - Feedback helps patient realize why Goal Met.
Decreased, Factors:
 Slurred speech delayed, or absent  Sedentary lifestyle
provided feedback. caregivers are not understanding or
 Left-side ability to receive,  Social drinker responding appropriately and provides 3. used resources
weakness  Smoker for more than opportunity to clarify meaning. appropriately.
process, transmit,
- BP: 150 / 80 mmHg 40 years Goal Met.
and/or use a system
 Vital signs taken of symbols. 4. Pointed to some objects and asked the - This is to test for expressive aphasia.
as follows: patient to name them. The patient may recognize item but not
- T: 36.4 C Signs and Symptoms:
be able to name it.
- PR: 88 bpm
- RR: 20 bpm  Slurred speech /
- BP: 150 / 80 5. Wrote a notice at the nurses’ station and - Allays anxiety related to inability to
incomprehensible
mmHg speech
patient’s room about speech communicate and fear that needs will
 Facial drooping (facial impairment. Provided a special call bell not be met promptly.
paralysis) that can be activated by minimal
pressure if necessary.

Impaired verbal 6. Provided alternative methods of - Provides communication needs of

communication communication: writing, pictures. patient based on individual situation
related to loss of and underlying deficit.
facial muscle tone as
evidenced by slurring 7. Anticipated and provided for patient’s - Helpful in decreasing frustration when
of speech. needs. dependent on others and unable to
communicate.
8. Talked directly to the patient, speaking - Reduces confusion and allays anxiety
slowly and distinctly. Phrased questions
 to be answered simply by yes or no. at having to process and respond to
Progressed in complexity as the patient large amount of information at one
responds. time.

9. Spoke to the patient in normal tones and

avoided talking too fast. Gave the
patient ample time to respond. Avoided - Raising voice may irritate or anger the
pressing for a response. patient. Forcing responses can result in
frustration and may cause the patient to
10.Encouraged significant others to persist resort to “automatic” speech.
in efforts to communicate with the
patient even if the patient is unable to - It is important for family members to
respond appropriately. continue talking to the patient to reduce
patient’s isolation, promote
establishment of effective
communication, and maintain sense of
11.Respected patient’s pre-injury connectedness with family.
capabilities; avoided “speaking down”
to the patient. - Enables the patient to feel esteemed,
because intellectual abilities often
remain intact.
DEPENDENT INTERVENTIONS:
1. Consulted and referred the patient to
speech therapist.
- Assesses the patient’s verbal
capabilities and sensory, motor, and
cognitive functioning to identify
deficits/therapy needs.

Reference: Reference:
Nurse’s Pocket Guide Nurse’s Pocket Guide
15th edition 15th edition
Doenges, Moorhouse, Doenges
Murr Page 152