Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation Subjective: Short Term Goal: Independent: Short Term Goal: Successfully Met

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ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired verbal Short Term Goal: Independent: Short Term Goal:
“Hindi talga siya communication r/t loss After 1-2hours of Introduce self and To gain trust from the Successfully Met
nakakapagsalita kahit oral muscle and facial appropriate nursing establish rapport to the patient for easier and After 1-2hours of
anung gawin niya.” muscle tone control intervention and patient. accesible appropriate nursing
-as verbalized by her 2nd adequate health implementation of intervention and
wife teachings, the patient intervention adequate health
will establish alternative teachings, the patient
methods of Ask client to follow To tests if patient can uses written flash cards
Objective: communication which simple commands such comprehend oral and pictures which
 Inability to produce needs can be expressed as “close and open Left communication or to provide visual clues of
speech such as: Hand” and “Close eyes” test for receptive expression and Uses of
 Uses “tounge aphasia. proper non-verbal
clicking” and  Use of writing Have client produce communications or
moaning. materials or written simple sounds, such as To assess functionality gestures to express
 Difficulty in use of flash cards and “Eh,” “Ah.” And “Sh” of patient’s motor needs.
facial expression pictures which component of speech
 decreased in muscle provide visual clues (tounge, lip movement
strength of the of expression. and breath control)
extremities  Use of proper non- Assess vision and
-Arms: L=5/5 verbal hearing ability. To determine any
R=0/5 communications or problems on vision and
-Legs: L=2/5 gestures. hearing which can alter
R=0/5 verbal and written
 GCS communication.
Eye opening= Provide alternative
4(spontaneously) methods of Provides for
Motor = communication, such as communication of
5 (localizes pain) writing or felt board and needs or desires based
Verbal= pictures. Provide visual on individual situation
2 (incomprehensible clues—gestures, or underlying deficit.
words) pictures, “needs” list,
and demonstration.
Determine ability to
read/write. Evaluate To determine if Written
musculoskeltal state and communication is
ability to hold pen. possible.

Talk directly to client,


speaking slowly and Reduces confusion and
distinctly. Use yes/no anxiety at having to
questions to start, process and respond to
progressing in large amount of
complexity as client information at one time.
responds. As retraining progresses,
advancing complexity of
communication
. stimulates memory and
further enhances word
and idea association.
Encourage family
members and visitors to It is important for
persist efforts to family members to
communicate with the continue talking to
patient. the patient to reduce
patients isolation,
promote
establishment of
effective
communication and
maintain sense of
connectedness or
bonding with the
family.
Name of Patient: Mr. CVA Student
Nurse: Eben Ezar H. Dela Cruz

Age: 66 y/o
SMU-SN

Diagnosis: CVA

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