Assessment/Cues Nursing Diagnosis Background Knowledge Objectives/Expected Outcome Nursing Intervention Rationale Evaluation
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.
Provide alternative methods of communication, like pictures, visual cues, methods and demonstration.
Pt. was able to established methods of communication in which needs can be expressed.
Talk directly to patient. Speak slowly and directly. Use yes or no questions to begin with.
Visual disturbance
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.
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.
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
Limited ROM
Right/Left hemiplegia
Impaired physical mobility R/t damage in the right/left hemispheres of the brain
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.
Plan care with rest periods between activities and increase activities
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).
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.
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