Care Plan for Stroke Patient: Comprehensive Nursing Plan for Mr. Lim

CARE PLAN
Introduction
Care plan provides directives for individualised care of the client. A care plan usually
flows from the list of the patient's diagnoses are usually organised as per the needs of the
patient. It is the means of communicating among the nurses in a changing environment. An
updated care plan transfer during the change in shift of the nurses are helps in reducing the
medical errors. It is the care plan that helps in teaching documentation (Party, 2012).
The case study of Mr. Lim provides us with the fact that he had suffered from a
sudden stroke, which called for an admission in to the emergency department. It has to be
remembered after the stroke patient can have difficulty in the memory, understanding,
attention, gait problem and decision making. It also affects the functional status of the
patient. It is evident that Mr. Lim had suffered from a partial paralysis of the left side of his
body. In order to restore the functional status of Mr. Lim it is necessary to chalk out a
comprehensive nursing plan that would include proper neurological assessment, monitoring
of the vital signs, pharmacological interventions, fall preventions strategies, maintenance
of gait, promotion of self-care, educating families.
The initial step to manage a patient who has just suffered from stroke is the proper
assessment technique. The initially we assessed the facial dropping of the patient, followed
by his slurry speech. It is evident that the patient was elderly, and the care for an elderly
patient requires more attention in comparison to the young patients. While providing care
to the patient, it was necessary to understand the pathophysiology of the clinical condition.
It is known that oxidative stress is the major factor in the damage caused by the stroke. This

oxidative damage is again more prone to the elderly people, establishing a link between
stroke and ageing.
After the assessment of the patient it is necessary to identify the needs of the
patient. The goal of the nurse, caring for the client us to achieve a status of perceived
optimum health and contentment (Grol et al., 2013). The nursing assessment requires to
provide with nurses the necessary information for diagnosing the status of each of the
areas. The goals of the assessment is to establish trust in the nurse client relationship.
The component of the senses framework that can be applicable in this case is the
sense of continuity and the sense of security. Considering the sense of continuity we made
sure that Mr. Lim experience a positive environment within the hospital stay and such that
the expectations of care are conveyed consistently and carefully. It can be identified that
Mr. Lim might face problems with mobility and impaired speech, hence the patient might
expect a supportive environment in the clinical setting (Lindsay et al., 2013). Nurses are
positioned to serve as the patient advocates and interdisciplinary leaders in the holistic
recovery of stroke in patients. A holistic wellness involved the readiness of a person to
change and be patient centred. Being a nurse we looked after the social, emotional,
spiritual, occupational, financial, intellectual, and physical and the environmental needs of
the patient. The approaches taken by us involved practicing self-awareness, addressing the
negativity, practicing gratitude and mindfulness (Lindsay et al., 2013). While addressing the
physical needs we identified pain, loss of mobility and incontinence in the patient.
Introduction of relaxation and breathing exercises, diet education, education regarding the
medicines, gait exercises, speech therapy, prayer, mindfulness ad meditation therapy has
been beneficial for this patient (Party, 2012).

Care plan template 1
Patient Name Mr Lim TK DOB 2/5/1948
Baseline recordings BP : 169/75mmHg HR : 90bpm
Temperature : 37.5’c RR : 24bpm
Mr Lim is a 70 years old, Chinese Male
Retiree, used to work as a chef.
Staying with Spouse 65years old, have a son who stays aboard.
Mr Lim has sudden onset of slurring of speech, facial droop over left side, weakness over
both left upper and lower limb while having breakfast with wife. Called ambulance
immediately.
Past Medical History of
1. Hypertension, Diagnosed 5 years ago
2. Type 2 Diabetic Mellitus, Diagnosed 3 years ago, On PO Glipizide BD.
The patient ranked 19 with the NH scale for the assessment of stroke. CT scan reports
showed hypersensitivity in the M1 segment of the Right Middle cerebral artery with no
other signs of ischemic stroke. The MRI scan reported a demonstrated an ischemic change
confined to the right middle cerebral artery.
Need Goal Nursing Intervention
1. Engage family
member to participate
in patient’s care
Short Term a) Physiotherapy and Occupational
therapy management
b) Care Giver training on patient’s