Mertalla, Mary Joy G.
September 6, 2010
NCM 501204-SEC.407
CEREBROVASCULAR ACCIDENT
NURSING DIAGNOSIS FOR ACUTE CARE SETTINGS
Ineffective tissue perfusion; cerebral related to interruption in blood flow
Possibly evidenced by:
Altered level of consciousness
Changes in motor and sensory responses
Vital sign changes
Desired outcomes: Demonstrate stable vital signs and absence of increased ICP
Actions/Intervention Rationale
Independent: Independent:
Monitor V/S and refer any Any changes on V/S is
deviations. neurological in pathology
Monitor and document Useful in determining location,
neurological status extent, and progression of CNS
damage.
Evaluate pupil reactivity To evaluate cranial nerves and
whether the brainstem is intact.
Collaborative: Collaborative:
Administer supplemental oxygen To reduces cerebral hypoxemia
as indicated
Administer medications as For treatment and prevent further
ordered: anticoagulant, cerebral damage
antihypertensive, peripheral
vasodilators, neuroprotective
agents,phenytoin, stool softeners
Impaired physical mobility related to neuromuscular involvement
Possibly evidenced by:
Inability to purposely move within the physical environment
Impaired coordination
Limited range of motion
Decreased muscle strength and control
Desired outcome: Maintain optimal position as evidenced by absence of
contractures, bedsores, and footdrop.
Actions/Intervention Rationale
Independent: Independent
Change positioning at least every 2 To promote circulations to
body tissues.
hours
Prop extremities in functional Prevent contractures and
position; use footboard, and place footdrop
head in neutral position
To prevent skin breakdown
Protect bony prominences using bed and bedsores
linens & cushion
To enhance circulation and
Massage affected side and bony
prevent pressure that cause skin
prominences and assist on shifting breakdown
weight at frequent intervals.
Passive Range of motion excercise To prevent muscle and joints
stiffness
Observe affected side for color,
edema, or other sign of compromised Edematous tissue is more
circulation. easily traumatized and heals
Collaborative: more slowly
Provide egg-crate mattres, water Collaborative:
Promotes even weight
bed, flotation devices or specialized
distribution & dec. Pressure on
bed.
bony points & prevent skin
breakdown.
Ineffective breathing pattern related to respiratory depression
Possibly evidenced by:
Changes in rate and depth of respirations
Reduced total lung volume
Cyanosis
Cessation of breathing when off the ventilator
Dyspnea or increased work of breathing
Presence of mechanical ventilator
Maintain effective respiratory pattern via ventilator with the absence of
retractions ;use of accessory muscle, cyanosis, or other signs of hypoxia
Actions/Intervention Rationale
Independent: Independent:
Observe and monitor breathing To observe for [Link]
pattern accuracy to support respiration
Auscultate chest for breath sounds, To assess for any retained
adventitious sound and symmetry secretions and degree of
of chest movement. oxygen delivered by [Link].
Elevate head of the bed To promote proper ventilation
Inflate tracheal cuff at frequent To promote tracheal circulation
interval and prevent tracheal damage
Check [Link] patency of tubing Kinks in tubing prevent
Check [Link] alarms for proper adequate volume delivery of O2
functioning To prevent accidental repiratory
Keep resuscitation bag at bedside distress
Monitor patients O2 sat To evaluate degree of tissue
Collaborative: oxygenation
Assess ventilator settings routinely Control setting are adjust
and readjust as indicated according to pt needs
NURSING DIAGNOSIS FOR STABLE CARE SETTINGS
Impaired verbal communication related to neuromuscular impairment
Possibly evidenced by:
Impaired articulation; cannot speak
Inability to modulate speech
Inability to produce written communication
Desired outcomes: Establish method of communication in which needs
can be expressed.
Actions/Intervention Rationale
Independent: Independent:
Assess type and degree of Choice of interventions
dysfunction depends on type of impairment
Provide alternative method of Provides for communication of
communication (visual, or gestures needs desires based on
clues) individual situation
Talk directly to patient, speaking Reduces confusion and anxiety
slowly & distinctly at having to process & respond
Speak in normal tones avoid to large amount of info. At one
speaking too fast and avoid pressing time
for a response & give pt. Time to Patient is not necessarily
respond hearing impaired & raising voice
Encourage significant others to may irritate or anger pt.
communicate w/ pt.(reading mail, To reduce pt. Isolation and
discussing family happenings) promote establishment of
Anticipate and provide for pt. Needs communication
Collaborative: Helpful in decreasing
Refer to speech therapist frustrations when dependent to
others &unable to com. Desires
To assess for rehabilitation
process
Self care deficit related to neuromuscular impairment
Possibly evidenced by:
Impaired ability to perform ADL’s(ex. Inability to bring food from
receptacle to mouth, wash body, ability to put on clothing, and
completing toileting task)
Perform self care activities within level of own ability
Actions/Intervention Rationale
Independent: Aids in anticipating planning for
Assess abilities and level of deficit meeting individual needs.
in performing ADL’s Pt may become fearful and
Avoid doing things for pt. That can dependent.
be done by her self
Maintain a supportive and firm Pt needs empathy
attitude
Enhances of self worth, promote
Provide positive feedback for efforts
independence & encouraged pt
and accomplishments
to continue endeavours
Provide self help devices (ex. long
handled brush, extensions for picking
Enables the pt to manage self,
up from floor etc)
enhancing independence & self
Create plan for visual deficits that
esteem
are present (ex. Place food & utensils
on the tray related to pt’s unaffected To provide proper visualization
side)
Re-establishes sense of
Encourage relatives to allow pt. To
independence and fosters self
do as much as possible for self.
worth and enhances
Collaborative:
rehabilitation process
Consult with Physical occupational
Provides experts assistance for
therapist
developing a therapy plan &
identifying special equipment
needs.
HEALTH TEACHING
Patient advise to continue medication regimen
Medications (antihypertensive drugs, Vasodilators and others drugs) and
drug compliance is emphasize to have an reversible
treatment in accordance to patient benefits.
Patient advised to perform pssive and active ROM to
Exercise prevent joints and muscle stiffness due to hemiplegia and
hemeparesis
Patient advised to undergo rehabilitation and refer for a
physical therapist and recreational therapist that resulted
from neuromuscular impairment.
Treatment
Patient is advised for frequent interval of check up to monitor
Outpatient condition and further treatment can be added to optimize
rehabilitation process.
(check-up)
Low in sodium and fat is recommended to prevent increased
high blood pressure and build up of fat in the blood stream
that causes atherosclerosis
Diet