DIVINE WORD COLLEGE OF SAN JOSE

NURSING DEPARTMENT
NURSING CARE PLAN
Name: C.G.
Age: 63
Address: Caminawit, San Jose
NURSING
DIAGNOSIS
Ineffective tissue
perfusion related to
impaired transport
of oxygen secondary
to cerebro vascular
accident

ANALYSIS
Decrease in oxygen
resulting in the
failure to nourish
the tissues at the
capillary level.

Medical Diagnosis:CVA
Attending Physician: DR. Francisco
Chief Complaint: Chest Pain
GOAL &
OBJECTIVES
GOAL
After series of nursing
interventions, the patient
will demonstrate increased
perfusion.

INTERVENTION

RATIONALE

Goal unmet.
Patient needs more seek
from doctors and more
advanced technologies in
determining her condition.

NANDA
I= kadalasan
sumasakit ang dibdib
ko
O= pale & weak
Dyspnea
Left hemiparesis
Difficulty of
swallowing
M= T=37.1
P=72
R=18
BP= 150/90

OBJECTIVES:
After 8 hours of nursing
interventions the patient
will:
Demonstrate
behaviors/lifest
yles changes to
improve
circulation

EVALUATION

Establish rapport to the

client and significant
others
Monitor and record vital
signs
Monitor and record I &
O

To have their full

cooperation
To have baseline data
To determine fluid
volume relative to
oxygen transportation
and circulation

 Elevate head of bed

maximize
tissue perfusion

Encourage quiet and

restful atmoshphere
Encourage increase
fluid intake
Administer oxygen to
the client

To promote circulation
Conserves energy
lowers tissue oxygen
demands.
To prevent from
dehydratrion
To compensate the
demand of oxygen
needed by the body

Instruct patient on
preventing shoulder
adduction

promote
wellnes

Encouraged patient to
frequently change
position of hands and
fingers

To promote circulation

Advised client to
exercise and provide
ROM

To decrease tension
level

Demonstrate use of
relaxation techniques
Maintain body
alignment in functional

position
Exercise affected limb
Assist and provide
comfort measures to the
patient
Instruct patient to place
food on the unaffected
side of the mouth