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    Patient's Profile: Mr. W 78 Years Old New England Right Cerebrovascular Accident (CVA) With Left Hemiparesis

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    Krisianne Mae Lorenzo Francisco
    Mr. W is a 78-year-old man who suffered a right cerebrovascular accident resulting in left hemiparesis. He is unable to perform activities of daily living such as eating, brushing teeth, and combing hair independently. The nursing diagnosis is self-care deficit related to neuromuscular impairment. The short-term goal is for Mr. W to demonstrate techniques and lifestyle changes to meet self-care needs by trying to feed himself within 8 hours. The long-term goal is for him to perform self-care activities within his ability level by bathing, eating, brushing teeth, and doing ADLs on his own within 6 months with nursing intervention.

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    Patient's Profile: Mr. W 78 Years Old New England Right Cerebrovascular Accident (CVA) With Left Hemiparesis

    Uploaded by

    Krisianne Mae Lorenzo Francisco
    142 views16 pages
    Mr. W is a 78-year-old man who suffered a right cerebrovascular accident resulting in left hemiparesis. He is unable to perform activities of daily living such as eating, brushing teeth, and combing hair independently. The nursing diagnosis is self-care deficit related to neuromuscular impairment. The short-term goal is for Mr. W to demonstrate techniques and lifestyle changes to meet self-care needs by trying to feed himself within 8 hours. The long-term goal is for him to perform self-care activities within his ability level by bathing, eating, brushing teeth, and doing ADLs on his own within 6 months with nursing intervention.

    Original Title

    NCP 3

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    Mr. W is a 78-year-old man who suffered a right cerebrovascular accident resulting in left hemiparesis. He is unable to perform activities of daily living such as eating, brushing teeth, and combing hair independently. The nursing diagnosis is self-care deficit related to neuromuscular impairment. The short-term goal is for Mr. W to demonstrate techniques and lifestyle changes to meet self-care needs by trying to feed himself within 8 hours. The long-term goal is for him to perform self-care activities within his ability level by bathing, eating, brushing teeth, and doing ADLs on his own within 6 months with nursing intervention.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    142 views16 pages

    Patient's Profile: Mr. W 78 Years Old New England Right Cerebrovascular Accident (CVA) With Left Hemiparesis

    Uploaded by

    Krisianne Mae Lorenzo Francisco
    Mr. W is a 78-year-old man who suffered a right cerebrovascular accident resulting in left hemiparesis. He is unable to perform activities of daily living such as eating, brushing teeth, and combing hair independently. The nursing diagnosis is self-care deficit related to neuromuscular impairment. The short-term goal is for Mr. W to demonstrate techniques and lifestyle changes to meet self-care needs by trying to feed himself within 8 hours. The long-term goal is for him to perform self-care activities within his ability level by bathing, eating, brushing teeth, and doing ADLs on his own within 6 months with nursing intervention.

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    patient's profile

    Name: Mr. W
    Age: 78 years old
    Address: New England
    Diagnosis: right
    cerebrovascular accident
    (CVA) with left hemiparesis
    Assessment
    Subjective:
    "I want to eat by myself but I
    cannot." as verbalized by the client.
    Assessment
    Objectives
    Unable to perform Activity of daily living such as eating, brushing
    teeth, and combing hair.
    hemiplegia
    hemiparesis
    Vital Signs:
    90%
    130/100mmHg

    13cpm

    96bpm
    Diagnosis

    Self - care deficit related to


    neuromuscular impairment as
    evidenced by hemiparesis.
    Planning
    SHORT TERM: AFTER 8 HOURS OF NURSING INTERVENTION,
    THE CLIENT WILL DEMONSTRATE TECHNIQUES AND LIFESTYLE
    CHANGES TO MEET SELF - CARE NEEDS AS EVIDENCE BY
    TRYING TO FEED HIMSELF.

    LONG TERM: AFTER 6 MONTHS OF NURSING INTERVENTION,


    THE CLIENT WILL PERFORM SELF - CARE ACTIVITIES WITHIN
    LEVEL OF OWN ABILITY AS EVIDENCE BY TAKING A BATH,
    EATING, BRUSHING TEETH, DOING ADL'S ON HIS OWN.
    Independent

    Nursing Intervention
    Intervention
    Keep the environment
    organized and uncluttered.

    Rationale
    Because patient with cognitive
    impairment is easily
    distracted.
    Intervention
    To assist the client in dressing
    aids, place the clothing on the
    affected side.

    Rationale
    In order in which the garments are
    to be put on.
    Intervention
    Allow the use of large mirror
    when dressing.

    Rationale
    to promote the client's awareness
    of what he or she putting in the
    affected area.
    Intervention

    Provide nonskid mats when


    eating.

    Rationale
    to stabilize the plate.
    Intervention
    Place plate guards when the client
    is eating.

    Rationale
    To prevent food from being
    pushed off plate.
    Intervention

    Support and encourage the


    patient in performing the
    activities.

    Rationale
    To prevent the patient from
    becoming overly fatigue and
    discourage.
    Collaborative Nursing

    Intervention
    Intervention
    Collaborate with the
    rehabilitation professionals
    for assistive devices and
    mobility aids such as cranes
    or crutches.
    Rationale
    To enhance client's capacity and
    promote independence.
    Project 4 name

    Client name:
    Presentations are tools that can be used as
    demonstrations, lectures, speeches, reports, and
    more. It is mostly presented before an audience.
    Evaluation
    SHORT TERM: AFTER 8 HOURS OF NURSING INTERVENTION,
    THE CLIENT DEMONSTRATED TECHNIQUES AND LIFESTYLE
    CHANGES TO MEET SELF - CARE NEEDS AS EVIDENCED BY
    TRYING TO FEED HIMSELF.

    LONG TERM: AFTER 6 MONTHS OF NURSING INTERVENTION,


    THE CLIENT PERFORMED SELF - CARE ACTIVITIES WITHIN
    LEVEL OF OWN ABILITY AS EVIDENCE BY TAKING A BATH,
    EATING, BRUSHING TEETH, DOING ADL'S ON HIS OWN.

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