VII.
NURSING MANAGEMENT
A.IDEAL NURSING INTERVENTIONS
Nursing Diagnosis
Nursing Interventions:
Activity Intolerance related
to right side body paralysis
1. Assess patients level of
functioning using the
functional mobility scale
2. Encourage bed exercises
3. Provide emotional support
and encouragement.
4. Turn and position patient at
least every hours
5. Involve patient in cure
related to planning and
decision making
Nursing Diagnosis
Nursing Interventions:
Rationale
To determine patients
capabilities
Prepares patient for late
activities but also offers
hope ascends of
optimism about
recovery.
To help improve
patients self-concept
and motivation to
perform
Turning helps prevent
skin breakdown by
relieving pressure
To improve compliance
Rationale
Self care deficit related to
musculoskeletal impairment
1.Observe, document and
report patients functional and
perceptional or cognitive ability
daily
Careful observation
helps you adjust
nursing actions to
meet patients needs
Applying therapy
consistently aids
patients independence
This allow patient to do
as much as possible
for self
To aid comprehension
Provides expert
assistive for
developing therapy
plan and identifying
special equipment.
2. Perform the prescribed
treatment for the underlying
condition. Monitor patients
progress and report favorable
and adverse responses
3. Provide assistive devices at
each meal as needed
4. Encourage patient to do as
much for self as possible,
giving simple instructions one
at a time
5. Consult with physician with
physical/occupational therapist
Nursing Diagnosis
Nursing Interventions:
Ineffective Tissue Perfusion
related to interruption of
blood flow
1.Elevate head of bed and
maintain head/neck in
Rationale
To promote
circulation/venous
midline or neutral position
drainage
2. Keep environment and
patient quiet, space nursing
interventions
This measures reduce
intracranial pressure
3. Maintain adequate
nutrition
To promote tissue
healing, oxygenation
and metabolism
Mobilizes excess fluid
oliguric renal failure or
edema and prevents ICP
Reduces hypoxia which
can cause cerebral
vasodilation and
increase
pressure/edema
formation
4. Administer diuretics such
as manitol as ordered
5. Administer supplemental
oxygen as indicated
Nursing Diagnosis
Nursing Interventions:
Impaired verbal
communication related to
impaired cerebral circulation
1. Review history for
neurological conditions that
could affect speech such as
stroke, tumor, MS, hearing
or vision impairment.
2. Ascertain that you have
Rationale
To assess
causative/contributing
factor
To assist client to
clients attention before
communicating.
3. Establish relationship with
the client, listening carefully
and attending to clients
verbal or non verbal
expression.
establish a means of
communication, to
express needs, wants,
ideas and questions.
To conveys interest and
concern
4. Maintain eye contact
preferably at clients level.
To establish
communication
5. Keep communication
simple, speaking in short
sentences, using
appropriate words.
To establish means of
communication
6. Plan for alternative
methods of communication
eg. Slate board,
letter/picture board and etc.
Nursing Diagnosis
Nursing Interventions:
Decarease Cardiac Output
related to altered stroke
volume
1.Determine vital
signs/hemodynamic
parameters including cognitive
status
2. Keep client on bed rest in
position of comfort
Rationale
To provide baseline for
comparison to follow
trends and evaluate
response to
interventions
Decrease oxygen
consumption and risk
for decompensation
3. Administer high flow oxygen
via mask as indicated
To increase oxygen
available for cardiac
function or tissue
perfusion.
4. Monitor vital signs
frequently
To note response to
intervention
5. Monitor cardiac rhythm
continuously
To note effectiveness of
medication
6. Decrease stimuli; provide
quite environment
To promote adequate
rest
Nursing Diagnosis
Nursing Interventions:
Acute Pain related to
inflammation of the veins
1.Assess for referred pain
as appropriate
2. Note clients attitude
toward pain and use of pain
medication
To assess
etiology/precipitating
factor
3. Obtain client assessment
of pain to include location,
To rule out worsening of
underlying condition or
Rationale
To help determine
possibility of underlying
condition
characteristics, onset and
duration, frequency, quality
and intensity
development of
complication
4. Use pain rating scale
appropriate for age and
cognition
To evaluate clients
response to pain
5. To monitor skin color and
vital signs
This are usually altered in
acute pain
To promote
pharmacological pain
management
7. Instruct in and encourage
use of relaxation techniques
such as deep breathing and
diversional activities
To destruct attention and
reduce tension
8. Administer analgesics
To maintain acceptable
level of pain
6. Provide comfort
measures, quite
environment and calm
activities
B. ACTUAL NURSING CARE PLAN
S
No subjective cues
>slurred speech noted
>right hemiplegia
> BP 150/100mmHg
Decrease Cardiac Output related altered stroke volume
Long term: At the end of 2 days of nursing interventions, patient will be
able to display hemodynamic stability
Short term: At the end of 8hrs nursing interventions, patient will be able to
maintain BP within normal range
>Vital signs taken and recorded
>Provided adequate rest
>Placed patient in high-fowlers position
>Encouraged passive ROM on the affected area and active ROM
exercises on the affected area
>Encouraged adequate rest periods.
>Encouraged to eat foods low in fat and salt
>Provided a quite and calm environment
>instructed to avoid activities that can stimulate valsalva maneuver
COLLABORATIVE:
>Administer antihypertensive drugs
>Latest BP= 150/100mmHg
>still hemiplegic, and with slurred speech
No subjective cues
>slurred speech
>right hemiplegia
>BP : 150/100 mmHg
>HGT : 201mg/dL
Ineffective tissue perfusion related to interruption of blood flow
Long term: At the end of 2 days of nursing interventions, patient will be
able to maintain adequate tissue perfusion
Short term: At the end of 8 hours nursing interventions, patient will be able
to improve tissue perfusion
>vital signs taken and recorded
>provided adequate bed rest
>assisted to perform active ROM exercises
>IVF regulated at desired rate
>change position every two hours
>Instructed proper diet, restriction to sweet, salty and high fat foods.
Collaborative Intervention:
>administer antihypertensive drug
S
O
BP : 150/100 mmHg
No subjective cues
>Right hemiplegia
Activity Intolerance related right side body paralysis
Long Term: At the end 2 days of nursing interventions, patient will report
measurable increase in activity intolerance.
Short term: At the end of 30 minutes of nursing interventions, patient will
demonstrate a decrease in physiological signs of intolerance
>Assessed patients ability to perform normal tasks noting reports of
weakness, fatigue and difficulty accomplishing tasks
>Elevated head of the bed as tolerated
>Recommended quiet atmosphere; bed rest if indicated.
>Changed position slowly; monitor for dizziness
>Planed activity progression with patient, provide assistance with
activities
E
Still with right hemiplegia
No subjective cues
S
O
> right hemiplegia
A Self care deficit related to musculoskeletal impairment
P Long Term: At the end 2 days of nursing interventions, patient will be able to
perform self care activities with assistance
Short term: At the end of 30 minutes of nursing interventions, patient will be
able to know the importance of proper hygiene
I
>bedside care done
>needs attended
>emphasized the importance of proper hygiene
>kept back dry
>assisted client in performing self care
E Able to understand the importance of proper hygiene
No subjective cues
S
O
Redness noted at the right arm
Facial grimace
A Acute pain related to the inflammation of the viens
P Long Term: At the end 2 days of nursing interventions, patient will report relief
of pain
Short term: At the end of 30 minutes of nursing interventions, patient will have
feeling of reduce pain.
I
>bedside care done
>assessed pain scale
>vital signs taken and recorded
>encouraged deep breathing technique
>encouraged diversional activities
>applied warm compress on the affected area
>provided comfort measures
E Still with redness on the right arm.
No subjective cues
S
O
Slurred speech
A Impaired verbal communication related to impaired cerebral circulation
P Long Term: At the end 2 days of nursing interventions, patient will indicate
understanding of the communication difficulty and plans ways of handling
Short term: At the end of 30 minutes of nursing interventions, patient will
establish method of communication in which needs can be expressed
I
>Established relationship with the client, listening carefully and attending to
clients verbal or non-verbal expression.
> Maintained eye contact preferably at clients level.
> Kept communication simple, speaking in short sentences, using
appropriate words.
> Planned for alternative methods of communication eg. Slate board,
letter/picture board and etc.
>Provided reality orientation by responding simple and honest statements
E Patient was able to established method of communication
