Nursing Care Plan

Cues Subjective: Dili klaro iyang pag.istorya og pagsulat as verbalized by the wife. Objective: -Inability to produce written communication -Inability to comprehend written/ spoken language.

Nursing Diagnosis Impaired verbal and written communication related to neurovascular impairment.

Objectives At the end of 8 hours of nursing intervention the client indicate an understanding of the communication problem.

Intervention Independent: 1. Listen for errors in conversation and provide feedback.

Rationale 1. Client may lose ability to monitor verbal output and unaware that communication is not sensible. Feedback helps client realize why caregivers are not understanding or responding. 2. Provides for communication of needs/ desire based on individual situation/ underlying deficit.

Evaluation At the end of 8 hours of nursing intervention the client indicated an understanding of the communication problem.

2. Provide alternative methods of communications like writing or felt board, pictures. Provide visualities (gestures, pictures, need list, demonstration. 3. Respect clients preinjury capabilities, avoid speaking down to client. 4. Ask client to write name and/or a short sentence. If unable to write, have client read a short sentence. Dependent 5. Consult w/ refer to speech therapist.

3. Enables client to feel esteemed because intellectual ability often remain intact. 4. Test for writing disability and deficits in reading comprehension

. 5. Assess individual verbal capabilities and sensory, motor

Nursing Care Plan Cues Subjective: Taas iyang bp as verbalizes by the wife. Nursing Diagnosis Hypertension related to CVD Objective Intervention Rationale Evaluation At the end of 8 hours nursing intervention client maintained bp within individually acceptable range.

At the end of 8 Independent: hours nursing 1. Observe skin intervention client color, maintain bp moisture, within individually temperature acceptable range. and capillary refill time.

Objectives: -sedentary lifestyle - elevated bp

1. Presence of pallor; cold, moisture skin, and delayed capillary refill time may be due to peripheral vasoconstricti ons or reflect cardiac decompositio n/ decrease

output. 2. Maintain activity restrictions like schedule periods of uninterrupted rest, assist client with self-care activities. 2. Reduce physical stress and tension that affect blood pressure and the course of hypertension.

3. Provide comfort measures; like back rest, neck massage, elevation of head. 4. Instruct relaxation techniques, guided Imagery, distractions

3. Decreases discomfort and may reduce sympathetic stimulation.

4. Can reduce stressful stimuli, procedure calming effect, and

therapy reducing BP. Dependent 5. Implement dietary restrictions like calories, refined carbohydrate s, sodium, fat and cholesterol as indicated. 5. These restrictions can help manage fluid retention and with associated hypertensive response, decrease myocardial workload.

Nursing Care Plan

Cues Subjective: kong naa syay kailangan ako ra ang gabuhat para niya as verbalized by the wife. Objective: -impaired ability to perform ADL like inability to bring food from receptacle to mouth - inability to warm body parts, -impaired ability to put on/ or take of clothing.

Nursing Diagnosis Self-care deficit related to decreased strength and endurance.

Objectives

Intervention

Rationale 1. These clients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for client to do as much as possible for self to maintain self-esteem and promote recovery. 2. May indicate need for additional intervention s and supervision to promote client safety. 3. Enhance sense of self-worth, promoting independen ce and encourage client to endeavors.

Evaluation At the end of 8 hours of nursing intervention the client demonstrated lifestyle changes to meet self-care needs.

At the end of 8 Independent: hours of nursing 1. Avoid doing intervention the things for client demonstrate client that lifestyle changes client can to meet self-care do for self, needs. providing assistance as needed.

2. Be aware of impulsive behavior /actions suggestive of impaired judgment. 3. Provide positive feedback for efforts and accomplish ments.