ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE
Subjective: N/A Impaired verbal Stroke is when a Short term: 1. Establish means of 1. Eye contact assures client Short term:
communication clogged or burst After 1 hour of communication, for of interest in After 1 hour of
Objective: related to impaired artery interrupts nursing example, maintain eye communicating; if client is nursing intervention,
Known case of Acute cerebral circulation blood flow deprives intervention, the contact; ask yes/no able to move head, blink the patient was able to
cerebral infarction as evidenced by the brain needed patient will be able questions; provide eyes, or is comfortable establish method of
Left MCA prob. incomprehensible oxygen and causes to establish method magic slate, paper and with simple gestures, a communication in
Embolic in nature sounds the affected brain of communication pencil, or picture or great deal can be done which needs can be
cells to die. It in which needs can alphabet board; use with yes/no questions. understood.
LOC: alert usually affects one be understood. sign language as Pointing to letter boards or
side of the brain. appropriate; and writing is often tiring to Long term:
GCS: 12 (E4V2M6) When brain cells Long term: validate meaning of client, who can then After 5 days of
die, the functioning After 5 days of attempted become frustrated with the nursing interventions,
Able to make of the body parts nursing communications. effort needed to attempt the patient will be
incomprehensible that they control is interventions, the conversations. Use of able to communicate
sounds impaired or lost. A patient will be able picture boards that express needs and desired
stroke can cause to communicate a concept or routine needs effectively.
paralysis or muscle needs and desired may simplify
weakness, loss of effectively. communication. Family
feelings, speech members and other
and language caregivers may be able to
problems, memory assist and interpret needs
and reasoning 2. Alerts all staff members to
problems, respond to client at the
swallowing bedside instead of over the
difficulties, 2. Place call light or bell intercom
problems of vision within reach and place
and visual note at central call
perception, coma, station informing staff 3. Helpful in reducing
and even death. that client is unable to frustration when
speak dependent on others and
3. Anticipate and meet cannot communicate
the needs of patients meaning.
4. Cues are often difficult to
recognize (glancing out of
the corner of the eye)

4. Recognize subtle cues 5. Naming objects and

 indicating the client is describing actions,
paying attention or thoughts, and feelings
attempting to helps the client to use
communicate. symbolic language.
5. Describe for the client 6. To maximize patient’s
what is happening, and sense of independence
put into words what the 7. To keep patient focused,
client might be decrease stimuli going to
experiencing the brain for interpretation,
6. Pace important objects and enhance the nurse’s
within reach ability to listen
7. Keep distractions such 8. It may be difficult for
as television and radio patients to respond under
at a minimum when pressure; they may need
talking to patient extra time to organize
8. Give the patient ample responses, find the correct
time to respond word, or make necessary
language translations
9. This approach provides the
patient with more channels
through which information
can be communication
10. The inability to
communicate enhances a
patient’s sense of isolation
9. Speak slowly and may promote a sense
of helplessness
11. Improves general
communication skills

10. Praise patient’s

accomplishments.
Acknowledge his or
her frustrations

11. Use and assist patient 12. SO may feel self-

or significant others to conscious in one-sided
 learn therapeutic conversation, but
communication skills knowledge that he or she
of acknowledgement, is assisting the client to
active-listening, and regain or maintain contact
messages with reality and enabling
12. Encourage family and client to feel part of family
SO to talk with client, unit can reduce feelings of
providing information awkwardness
about family and daily 13. Enhances participation and
happenings commitment to plan

Collaboration
1. Specialized services
may be required to
meet the patient’s
needs.
13. Involve family and
significant others in
plan of care as much as
possible
Collaboration
1. Refer to appropriate
resources (e.g.
speech therapist,
group therapy,
individual/ family
and/ or psychiatric
counselling)