Question

Make a Nursing Care Plan for these following: Ischemic Stroke with normal blood pressure

Answer 1

ISCHEMIC STROKE, CVA is a sudden loss of function resulting from disruption of blood supply to a part of the brain.

Causes -

• large artery thrombosis
• small penetrating artery thrombosis
• cardiogenic emboli
• cryptogenic

Clinical manifestations are -

• numbness, weakness of the face and arm or leg especially one side of the body.
• confusion
• change in mental status
• trouble speech
• visual disturbances
• motor loss
• sudden severe headache

NURSING CARE PLAN/ NURSING DIAGNOSIS-

• impaired physical mobility related to hemiparesis, loss of balance, and coordination.

GOAL: IMPROVED MOBILITY

INTERVENTIONS:

• CORRECT THE POSITIONING  IS IMPORTANT TO PREVENT CONTRCTURES. WHEN THE PATIENT IS HAVING STROKE CONTROL OF VOLUNTARY MUSCLES IS LOST, ARMS TEND TO ADDUCT, ROTATE INTERNALLY, ELBOW AND WRIST TEND TO FLEX, AFFECTED LENGS TEND TO ROTATE EXTERNALLY.
• MEASURE USED TO RELIEVE PRESSURE SUCH AS USE OF PILLOW AND COMFORTING equipment.
• ASSIST IN MAINTAINING GOOD ALIGNMENT,
• PREVENT COMPRESSIVE NEUROPATHIES ESPECIALLY ULNAR AND PERONEAL NERVES. A POSTERIOR SPLINT CAN BE APPLIED TO PATIENT AT NIGHT.
• CHANGE POSITION FREQUENTLY EVERY 2 HOUR.
• ESTABLISH AN EXERCISE PROGRAM
• PREPARE FOR AMBULATION. ASSIST PATIENT IN MAINTAINING BALANCE OUT OF THE BED,

EVALUATION: achieves improved mobility.

NURSING DIAGNOSIS 2:

• self-care deficit related to stroke sequelae.

GOALS: ACHIEVEMENT OF SELF CARE

NURSING INTERVENTIONS

• AS SOON AS PATIENT CAN SIT UP ENCOURAGE FOR SELF CARE ACTIVITIES.
• SET REALISTIC GOALS
• USE UNAFFECTED SIDE FIRST FOR SELF CARE LIKE COMBING, BRUSHING, SHAVING WITH ELECTRIC RAZOR, ETC
• USE ASSISTIVE DEVICES FOR AFFECTED SIDE SUCH AS SMALL TOWEL, BOXED PAPER TISSUE.
• INSTRUCT FAMILY TO BRING CLOTHES LARGER THAN PATIENT SIZE, FIT THE CLOTHES BY VELCRO.
• SUPPORT AND ENCOURAGEMENT ARE PROVIDED AND PREVENT OVERLY FATIGUED AND DISCOURAGEMENT.

NURSING DIAGNOSIS 3

• disturbed sensory perception related to altered sensory reception, transmission, and integration

GOALS: RELIEF OF SENSORY AND PERCEPTUAL DEPRIVATION.

NURSING INTERVENTIONS:

• PATIENT WITH VISUAL DEFICIT SHOULD BE APPROACH FROM WHERE VISUAL PERCEPTION IS INTACT.
• ALL VISUAL STIMULI SUCH AS CALENDAR, TV, BOOKS ETC SHOULD BE PLACED ON THAT SIDE,
• PATIENT CAN BE TAUGHT ABOUT THE MOVING HEAD IN THE DIRECTION OF DEFICIT VISUAL FIELD TO COMPENSATE FOR THIS LOSS.
• NURSE SHOULD MAKE EYE CONTACT WITH PATIENT TO DRAW HIS ATTENTION, ENCOURAGE CLIENT TO TALK.
• USE NATURAL OR ARTIFICIAL LIGHTING IN ROOM AND PROVIDE EYEGLASSES TO INCREASE VISION.
• ALSO MAINTAINING ALIGNMENT IS IMPORTANT TO PREVENT AMORPHOSYNTHESIS.

EVALUATION: IMPROVED VISION'

OTHER NURSING DIAGNOSIS CAN BE :

• impaired swallowing.
• acute oain related to hemiplegia and disuses.
• incontinence related to flacced bladder, confusion or inability to speak.
• disturbed thought process related to brain damange, confusion, inability to follow instructions.
• impaored verbal communication related to brain damage.
• risk of impaired skin integrity related to immobility.
• sexual dysfunction related to neurologic deficit,
• interrupted family process related to disease condition.