Cerebrovascular Accident NCP NURSING CARE PLAN

1. Ineffective tissue perfusion: cerebral 2. Impaired swallowing 3. Disturbed sensory perception 1. visual 2. kinesthetic 4. Unilateral neglect 5. Impaired verbal communication 6. Impaired physical mobility 7. Self-care deficit 8. Impaired urinary elimination: incontinence 9. Disturbed thought processes 10. Risk for injury: falls, burns, and lacerations 11. Risk for aspiration 12. Potential complications 1. increased intracranial pressure 2. corneal irritation and abrasion 3. subluxation of shoulder 13. Disturbed self-concept 14. Ineffective coping 15. Interrupted family processes 16. Deficient knowledge, Ineffective therapeutic regimen management, or Ineffective health maintenance 1. 2. 3. 4. 5. Additional Diagnoses Imbalanced nutrition: less than body requirements Risk for constipation Sexual dysfunction Fear/Anxiety Grieving

CUES Subjective: Ayoko pang kumain, gusto ko lang matulog ng matulog as verbalized by the client

Nursing Diagnosis Risk for injury related to left hemiplegia secondary to CVA

Inference CVA patient is at risk for injury since it may affect the anterior or middle cerebral artery leading to an infarction in the motor strip of the frontal cortex and this may cause hemiparesis or hemiplegia with manifestations it may predisposed an individual for any injury since part of their body is not functioning well.

Planning Short term: After 4 hours of nursing intervention, patient will be able to seek help to perform tasks that are beyond her capabilities. Long term: After 3 days of nursing intervention, patient will be able to remain free from injury absence of abrasions and falls

Interventions Independent: 1. Establish rapport

Rationale

Evaluation

To promote cooperation To have a baseline data

2. Monitor Vital signs

Objective: - Dizziness - Muscle strength test of left arm ; left leg - Needs assistance in performing ADL - BP of 160/80 - w/ limited movements

3. Assessed patient s general physical condition

To note for any abnormality

After 4 hours of nursing intervention the patient have seek help to perform task that are beyond her capabilities

4. Performed muscle strength test

To help reduce risk of second attack & prevent a rise in BP To protect from falling out of bed. To promote circulation and prevent contracture And to determine muscle functioning on the extremities

5. Keep side rails up

After 3 days of nursing intervention patient have remained free from injury absence of abrasions and falls.

6. Instructed patient on PROM ( passive range of motion)

7. Determine readiness to engage in activities/ exercises

To assess expected level of participation

Dependent: 1. Administer medications as ordered - Antihypertensive drug. ( hydralazine )

- It relaxes arteriolar smooth muscles to cause vasodilation and decreased blood pressure.

Collaborative: 1. Refer to social service or therapist. To relieve body weakness

SUBMITTED BY: VECENA, JOYCE SN.PHCM A4AB