NURSING CARE PLAN
NURSING
CUES
DIAGNOSIS
Subjective:
“Ga lisud gyud syag lihok
saiya lawas kay murag naa
syay mabati nga kasakit.”
As verbalized by the SO
Objective:
 Patient is
bedridden.
 Limited range of
motion observed.
 Uncoordinated
movements
observed.
 Inability to move
the left upper and
lower extremities
observed.
 Restlessness
noted.
 Dependent and
unable to
participate in
activity.
 Difficulty in turning.
OBJECTIVE INTERVENTION
Impaired After 8 hours of
 Monitored vital signs q
Physical rendering nursing
hour
interventions, the client
Mobility will be able to improve
 Monitored and recorded
and increase strength neurological status
and function of affected using Glascow Coma
and compensatory body scale.
parts.
 Monitored intake and
output and specific
gravity.
 Assisted the client in
repositioning herself.
 Provided safety
measures such as
putting pillow on
bedside of the patient
to prevent fall.
 Aught perform active
ROM exercises on
unaffected limbs w/in
lvls of patient’s
intolerance.
 Performed passive
ROM in affected limbs
at least three to four
times daily. Exercises
are done slowly to allow
the muscles time to
relax and support the
extremity done and
RATIONALE EVALUATION
 For baseline data
 To determine and
prevent life-
threatening
complications such
as severe
hypertension and
increase ICP
 Because of cerebral
edema, fluid
balance must be
regulated. Fluids
may be restricted if
the patient has
significant increase
in ICP.
 Helps the client in
performing ADL’s
 Enhances safety.
 Active ROM
increases muscle
mass, tone and
strength and
improve cardiac and
respiratory function.
 A voluntary muscle
will lose tone and
strength and
becomes shortened
 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.