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NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Impaired After 8 hours of  For baseline data


“Ga lisud gyud syag lihok  Monitored vital signs q
Physical rendering nursing
saiya lawas kay murag naa hour  To determine and
interventions, the client
syay mabati nga kasakit.” Mobility will be able to improve prevent life-
As verbalized by the SO  Monitored and recorded threatening
and increase strength neurological status complications such
and function of affected using Glascow Coma as severe
Objective: and compensatory body scale. hypertension and
parts. increase ICP
 Patient is  Monitored intake and
bedridden. output and specific  Because of cerebral
 Limited range of gravity. edema, fluid
motion observed. balance must be
 Uncoordinated  Assisted the client in regulated. Fluids
movements repositioning herself. may be restricted if
observed. the patient has
 Inability to move  Provided safety significant increase
the left upper and measures such as in ICP.
lower extremities putting pillow on
observed. bedside of the patient  Helps the client in
 Restlessness to prevent fall. performing ADL’s
noted.
 Dependent and  Aught perform active  Enhances safety.
unable to ROM exercises on
participate in unaffected limbs w/in  Active ROM
activity. lvls of patient’s increases muscle
 Difficulty in turning. intolerance. mass, tone and
strength and
 Performed passive improve cardiac and
ROM in affected limbs respiratory function.
at least three to four
times daily. Exercises  A voluntary muscle
are done slowly to allow will lose tone and
the muscles time to strength and
relax and support the becomes shortened
extremity done and
below the joint to from reduced range
prevent strain on joints of motion and lack
and tissues. Stopped of exercise.
point when pain and
resistance is met.  Reduces fatigue
and maximize
 Scheduled activities energy production.
with adequate rest
periods during day.  Prolonged
immobility and
impaired
 Kept patient’s head and neurosensory
neck in neutral position. function can cause
permanent
contractures.

 Reduces fatigue
and maximize
energy production.

 This position
promotes venous
drainage from the
brain and decreases
ICP.