NCP Self Care Deficit

 

Nursing Care Plan Assessment

Subjective: “Ng nagsimula ang  panghihina ng kaliwang  parte ng aking katawan ay hindi ko na maasikaso ang sarili ko” as verbalized  by the patient

Objective:

- (+) leftsided body weakness - Limited Range of  Motion with muscle strength of  3/5

- Requires help from his live-in  partner in order for him to sit, eat and drink  medication. - Patient is unable to wash his  body and put on clothes alone.

Nursing Diagnosis

Inference

Planning

Short term HyperSelf care tension deficit Goal: related to After 2 Occlusion neurohours of  within muscular  nursing impairment vessels of  intervention the brain secondary to Cerebro-  parenchyma the patient will be able Vascular  Disruption to identify infarction of blood individual as supply in areas of  evidenced the brain needs and  by (+) leftarea  perform sided body self-care weakness, Tissue and activities Limited cell necrosis within level Range of  Motion Destruction of own ability as with of Neuroevidenced muscle muscular   by proper  strength of   junctions hygiene and 3/5, Interruption self inrequires in transport- dependence. help from others to do tation of  electrical daily impulses to activities. the neuromuscular    receptors

Left Sided Weakness of the body

Intervention

Rationale

Independent: 

- Reviewed Medication regimen for   possible effects on alertness, energy level,  balance and  perception. - Developed a  plan regarding  patient care with the patient and relatives

- to determine issue affecting ability of  individual to  participate in own care - to implement the right care and comfort for  the patient

- Demonstrated to the patient and - to enhance relatives the right  patient knowledge way of proper  and infeeding, beddependence  bathing, and to do daily giving activities medications.

- Performed and demonstrated to the patient and

- to increase the muscle

relatives on how to do an activeassistive range of  motion exercises.

strength and to prevent unilateral neglect

- Provided an adequate rest  periods as well as comfort and safety measures to the patient.

- To prevent further  stress, fatigue and injury.

Evaluation

Short term Goal:

After 2 hours of  nursing intervention the patient are already able to identify individual areas of  needs and  perform self-care activities within level of own ability as evidenced  by proper  hygiene and self independence.

Goal met!