|SUBJECTIVE DATA |
|“Nahihirapan ako magsalita” |● |
|I’m having a hard time talking | |
|OBJECTIVE DATA |
|B/P: 160/80 |● |
|Diet: Low Salt Low Fat |● |
|Difficulty producing speech |● |
|Needs assistance when moving |● |
|Limited ability and difficulty to perform |● |
|gross motorskills like extending and | |
|lifting of his left extremities | |
|Poor muscle tone |● |
|Slowed Movement |● |
|DIAGNOSTICS |
|NURSING DX/PROBLEM |
| | |
| |Decreased Cardiac Output r/t altered |
|● |heart rate. |
|EXPECTED OUTCOME |
| After the nursing interventions, the|
|client will participate in activities that |
|reduce the workload of the heart. |
|NURSING DX/PROBLEM |2 |
| |Deficient Knowledge related to | |
| |condition, treatment and self-care. | |
|● | |● |
| | | |
|EXPECTED OUTCOME |
|After the nursing interventions, the client will |
|verbalize understanding of condition, prognosis, |
|and treatment after the 8-hour shift. |
|NURSING DX/PROBLEM |3 |
| |Impaired physical immobility r/t | |
| |neuromuscular damage involvement | |
|● | |● |
|EXPECTED OUTCOME |
| |
|NURSING DX/PROBLEM |4 |
| |Impaired verbal communication related| |
| |to loss of facial or oral muscle tone| |
| |control | |
|● | |● |
|EXPECTED OUTCOME |
|After the nursing interventions, the patient will|
|establish method of communication in which needs |
|can be expressed. |
|INTERVENTIONS |P |
|● |Establish rapport | |
|● |Place client in a comfortable position| |
|● |Monitor and record V/S | |
|● |Identify modifiable risk factors like | |
| |diet high in sodium, saturated fats | |
| |and cholesterol | |
|● |Reinforce the importance of adhering | |
| |to treatment regimen and keeping | |
| |follow up appointments. | |
| |Determine blocks to learning such as | |
| |language barriers and level of | |
| |understanding. | |
| |Explain the action, side effects and | |
| |adverse effect of the drugs being | |
| |given to the client. | |
|● |Provide alternative methods of | |
| |communication, like pictures or visual| |
| |cues, gestures or demonstration. | |
|● |Use yes/no questions to begin with. | |
|● |Speak in normal tones and avoid | |
| |talking too fast. Give patient ample | |
| |time to respond. | |
|● |Determine degree of immobility | |
|● |Support affected part with pillows | |
|● |Give rest periods to activities | |
|● |Encourage adequate fluids and right | |
| |diet as necessary to the client | |
|TEACHING |P |
|● |Encourage adequate intake of fluids | |
| |and nutritious foods to maximize | |
| |energy production. | |
|● |Encourage patient to not to hesitate | |
| |when asking questions if she cannot | |
| |understand a procedure or teaching. | |
|● |Advice the client to avoid stress. | |
| |Additional stress may contribute | |
| |fatigue and hypertension. | |
|● |Advice to take frequent short rests to| |
| |minimize energy consumption. | |
|PHARMACOLOGY |P |
|● |Amlodiphine | |
|● |Morelax | |
|● |Cholinerv | |
|● |Pantoloc | |
|INTERDISCIPLINARY NOTES (PDAR)
| | | | |Date and Time |NOTES | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | |