Medical Diagnosis: Cerebrovascular Accident
Problem: Self Care Deficit Neuromuscular Impairment
Assessment Nursing Diagnosis
Subjective: (none) Nursing Diagnosis
Objective: Self Care Deficit
 with soiled clothes neuromuscular impairment
 with unsatisfying secondary to CVA
appearance
 with minimal Scientific Explanation
sweating
 uncombed hair Self care deficit - impaired
ability to perform or
 Restlessness
complete task like feeding,
 Weakness
bathing/hygiene, dressing
 Discomfort
and grooming or toileting
activities of oneself.
*Cerebrovascular disease
(CVA) or stroke refers to any
physical or structural
abnormality of the brain
caused by a pathological
condition of the cerebral
vessels or the entire
cerebrovascular system. This
pathology either causes
hemorrhage from a tear of
vessel wall or impairs the
cerebral circulation by a
partial or complete occlusion
of the vessel lumen with
transient or permanent
effects
Planning Interventions
Short Term: Dependent
After 4 hrs of nurse (none)
patient interaction, the
patient or significant Independent
others will be able to 1. Establish rapport
identify personal
resources that can provide
assistance and be able to
2. Monitor vital signs
verbalize knowledge of
health care practices.
3. Wear clothing with
zipper closures, basin or
Long Term:
cups on personal
After few days the patient
hygiene articles for
or significant others will brushing teeth, combing
be able to demonstrate
hair, clothing that is
techniques/ lifestyle
easily managed to dress
changes to meet self-care
and undress
needs.
4. Assess client’s muscle
strength, gross and fine
motor coordination
5. Determine individual
strengths and skills of
the client
Collaborative:
(none)
Rationale of Intervention Evaluation
Patient or significant
others shall have
identified personal
resources that can
1. To promote provide assistance and be
cooperation able to verbalized
knowledge of health care
2. To have a baseline practices and be able to
data
demonstrated
techniques/ lifestyle
3. Provides safe support
changes to meet self-care
for immobility and
needs or the significant
other self care
activities to promote others will be able to
perform the health care
independence.
practices for the patient.
4. To identify/note
probable
management/plan of
care, severity of the
condition
5. To identify plan of
care; to know client’s
needs for assistance
(weaknesses)