Question

A. Chose a nursing Diagnosis, for example: Cerebrovascular Attack (CVA or Stroke), no breathing, Slow breathing, no BM, no urinary out put, Fever, Chills ; whatever.....
Just chose from one of the above mentioned examples, then:
B. Create your first care plan using these nursing process ( Assessment, Nursing Diagnosis, Planning, Implementation and Evaluation).

Answer 1

Assessment

Persons acutely ill with a CVA need special attention paid to the neurological assessment. The nurse will maintain life support systems as necessary, since the cardiovascular and respiratory systems will usually be compromised. The nurse should also keep in mind the underlying cause of the stroke. There will be a different treatment for strokes caused by hemorrhagic disorders as opposed to the thrombo-embolitic disorder.

Responsiveness: Changes in level of consciousness, changes in response to stimuli
Spontaneous movements: Changes in muscle tone, movements in the extremities, body posture, position of head and/or neck.
PERL: Perform a complete pupil check with recording the size of pupils
Skin: Temperature of skin, moisture, and color
Speech: If able/ if conscious, note changes in ability and/or quality
Reflexes: Assess deep tendon reflexes and the superficial reflexes
Presence of bleeding
Maintenance of blood pressure

During the postacute phase, assess the following functions:

Mental status (memory, attention span, perception, orientation, affect, speech/language).
Sensation and perception (usually the patient has decreased awareness of pain and temperature).
Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function.
Continue focusing nursing assessment on impairment of function in patient’s daily activities.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses for a patient with stroke may include the following:

Impaired physical mobility: related to hemiparesis, loss of balance and coordination, spasticity, and brain injury.
Acute pain related to hemiplegia and disuse.
Deficient self-care related to stroke sequelae.
Disturbed sensory perception related to altered sensory reception, transmission, and/or integration.
Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating.
Disturbed thought processes related to brain damage.
Impaired verbal communication related to brain damage.
Risk for inpaired skin integrity related to hemiparesis or hemiplegia and decreased mobility.
Interrupted family processes related to catastrophic illness and caregiving burdens.
Sexual dysfunction related to neurologic deficits or fear of failure.

Planning & Goals
cerebrovascular accident (stroke) Nursing care plans

The major goals for the patient and family may include:

Improve mobility.
Avoidance of shoulder pain.
Achievement of self-care.
Relief of sensory and perceptual deprivation.
Prevention of aspiration.
Continence of bowel and bladder.
Improved thought processes.
Achieving a form of communication.
Maintaining skin integrity.
Restore family functioning.
Improve sexual function.
Absence of complications.

Nursing Interventions

Positioning : Position to prevent contractures, relieve pressure, attain good body alignment, and prevent compressive neuropathies.
Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
Prevent edema. Elevate affected arm to prevent edema and fibrosis.
Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and begin walking as soon as standing balance is achieved.
Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.
Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual perception is intact.
Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in teaching alternate swallowing techniques.
Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
Be consistent in patient’s activities. Be consistent in the schedule, routines, and repetitions; a written schedule, checklists, and audiotapes may help with memory and concentration, and a communication board may be used.
Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.

Evaluation

1.      Expected patient outcomes may include the following:

Improved mobility.
Absence of shoulder pain.
Self-care achieved.
Relief of sensory and perceptual deprivation.
Prevention of aspiration.
Continence of bowel and bladder.
Improved thought processes.
Achieved a form of communication.
Maintained skin integrity.
Restored family functioning.
Improved sexual function.
Absence of complications.