Nursing Care Plan Cerebrovascular Accident

Assessment/Cues Nursing Diagnosis Background Knowledge Objectives/Expected Outcome Nursing Intervention Rationale Evaluation

Subjective (Symptoms): Nahihirapan akong magsalita. as verbalized by the client

Impaired verbal communication R/t loss of facial or muscle control

CVA affects specific part s of the brain, and if it affects the Brocas area which controls our speech, it may impair the pts. ability to speak. Damage to the speech area of the brain can impede a pts ability to comprehend speech.

Pt. will establish methods of communication in which needs can be expressed.

Provide alternative methods of communication, like pictures, visual cues, methods and demonstration.

Provide communication needs based on individual situation.

Pt. was able to established methods of communication in which needs can be expressed.

Have trouble understanding speech.

Impaired comprehension of speech R/t damage in speech area

Pt. will have regained his ability to understand speech.

Talk directly to patient. Speak slowly and directly. Use yes or no questions to begin with.

Visual disturbance

Impaired visual capability R/t damage in the brains visual area

CVA affects specific part s of the brain, and if it affects the occipital lobe wherein the visual area is located, it may impair the pts. ability to see clearly.

Pts visual acuity will have improved.

Perform vision tests and visual acuity tests by using Snellen chart (as ordered by the doctor).

Reduces confusion and anxiety on the part of the patient not having to process and respond to large amount of information at one time. To measure visual acuity, determine problems of peripheral vision and therefore give the necessary medications.

Pt. regains his ability to understand speech normally.

Pts visual acuity improved.

Objective (Signs): BP: 150/100 mm Hg PR: 74 bpm RR: 30 breaths/min T: 36.4 C

Stable vital signs

CVA affects the cerebral cortex of the brain that controls our speech, memory, logical and emotional response and voluntary movements so vital signs are stable Damage to the primary motor area of the brain can impede our ability to move our skeletal muscles. Hemiplegia is a condition in a person cannot partially or fully move one side of the body because the blood flow is cut off to either on the right or left hemispheres of the brain. Motor deficits are the most obvious effects of stroke. Symptoms are

Maintain stability of vital signs

Monitor vital signs

To maintain stable vital signs

Pt. maintains stable vital signs.

Limited ROM

Impaired physical mobility R/t primary motor area damage

Pt. will be able to regain full control of his muscles.

Assist patient to do passive range of motion.

To promote optimal level of functioning and to promote blood circulation.

Pt. regains full control of his skeletal muscles.

Right/Left hemiplegia

Impaired physical mobility R/t damage in the right/left hemispheres of the brain

Pt. will be able to move the affected body side.

Assist pt. to do passive ROM to all limbs and progress to assistive and then active ROM in all joints four times a day, focusing on the affected body side.

To promote circulation, muscle tone, joint flexibility and to prevent contractures and weakness.

Pt. can move the affected body side.

Slowed movement/ Difficulty turning

Activity intolerance R/t generalized weakness

Pt. will be able to regain full control of his muscles.

Plan care with rest periods between activities and increase activities

To decrease fatigue and to manage activities within limits.

Pt. regains full control of his skeletal muscles.

caused by the destruction of motor neurons in the pyramidal pathways (nerve fibers in the brain and passing through the spinal cord to motor tract.)

gradually (slowly).

With unsatisfying appearance

Self Care Deficit R/t musculoskeletal impairment

Motor deficit are the most obvious effect s of stroke. Symptoms are caused by destruction of motor neurons in the pyramidal pathways (nerve fibers in the brain and passing through the spinal cord to the motor tract.) One of those symptoms could be inability to perform ADLs.

Pt. will demonstrate techniques/ lifestyle changes to meet self-care needs

Use assistive devices appropriate for clothing with zipper and closures. Provide suction cups on personal hygiene articles for brushing teeth, combing hair, clothing that is easily managed to dress and undress

Provides safe support for immobility and other self care activities to promote independence

Pt .shall have demonstrated techniques/ lifestyle changes to meet self-care needs