Cues

Nursing Diagnosis Impaired bed mobility related to decreased motor agility or muscle weakness

Long Term

Short Term

Intervention

Rationale

Evaluation

Nahihirapan ako umurong. (+) Inability to turn from side to side (+) Inability to lift self up (+)Inability to scoot

The patient will report an increase in the strength and endurance of her muscles in the lower limbs

Within the shift, the patient will report satisfaction in her bed mobility

Assisted patient in positioning

Encouraged patient to try to move her legs Repositioned patient frequently Performed passive ROM Raised side rails Health teaching regarding the benefits of exercises in maintaining muscle strength

To prevent Goal Met injury and to make the patient comfortable To give the patient the sense of control of her situation To promote good circulation and prevent bed sores To maintain muscle tone and strength To promote patient safety To motivate the patient in exercising

Cues

Nursing Diagnosis Impaired communication related to impaired motor function of muscles of speech secondary to CVA

Long Term

Short Term

Intervention

Rationale

Evaluation

Hindi mo ako naiintindhihan. (+) Difficulty in articulating words (+) low hearing

The patient will be able to gain good ways to communicat e

Within the shift, the patient will report improved satisfaction in the way she communicat es

Anticipated patients needs Listened attentively to patient Maintained eye contact when speaking to the patient Use short simple sentences Observed nonverbal cues Talked slowly

To save Goal Met patients energy in talking To 7understand what the patient is trying to say To let the patient know that you are listening For the patient to easily hear and understand To further understand that the patient is trying to say For the patient to understand what was being said

Cues

Nursing Diagnosis Risk for aspiration related to inability to elevate upper body

Long Term

Short Term

Intervention

Rationale

Evaluation

(+) weak movements (+) fatigue (+) Impaired bed mobility (+) Inability to lift self up

The patient will maintain a patent airway

Within the shift, the patient will not experience aspiration

Raised head of bed when the patient is drinking and eating Encouraged the patient to chew thoroughly Keep the head of bed raised 30-45 mins after eating Offer food that is easy to swallow

To prevent aspiration

Goal Met

To make food easier to swallow and prevent aspiration To prevent regurgitation and aspiration of food To prevent aspiration

I.

Implemented Nursing Care Plan