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Assessment

Diagnosis

Planning

Nursing Intervention
Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 04 scale.

Rationale
Identifies strengths/deficiencies and may provide information regarding recovery. Assists in choice of interventions, because different techniques are used for flaccid and spastic paralysis. Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus. Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe. Prevents contractures/foot drop and facilitates use when/if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.

Evaluation

Objective:

- Inability to purposefully move within the physical environment - impaired coordination; limited range of motion -decreased muscle strength/cont rol

Impaired Physical Mobility related to paresis as evidenced by inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength / control

After 8 hours of nursing intervention the pt. will:


- Maintain/increase strength and function of affected or compensatory body part. - Maintain optimal position of function as evidenced by absence of contractures, foot drop. - Demonstrate techniques / behaviors that enable resumption of activities. - Maintain skin integrity.

After 8 hours of nursing intervention the pt. has: - Maintained/increased strength and function of affected or compensatory body part. - Maintained optimal position of function as evidenced by absence of contractures, foot drop. - Demonstrated techniques/behaviors that enable resumption of activities. -Maintained skin integrity. Goal met.

Change positions at least every 2 hrs. (Supine, side lying) and possibly more often if placed on affected side. Position in prone position once or twice a day if patient can tolerate.

Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.

1. Left side body paralysis

1. Left side body paralysis

Assessment

Diagnosis

Planning

Nursing Intervention

Rationale

Evaluation

Assist to develop sitting balance (e.g., raise head of bed; assist to sit on edge of bed, having patient use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance (e.g., put flat walking shoes on patient, support patients lower back with hands while positioning own knees outside patients knees, assist in using parallel bars/walkers). Encourage patient to assist with movement and exercises using unaffected extremity to support/move weaker side.

Aids in retraining neuronal pathways, enhancing proprioception and motor response.

May respond as if affected side is no longer part of body and needs encouragement and active training to reincorporate it as a part of own body.

4. Slurred speech

Assessment Objectives: Slurred speech

Diagnosis Impaired verbal communication related to impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatig ue

Planning The patient will be able to: Establish method of communication in which needs can be expressed. Use resources appropriately. Practice and implement speech therapy activities while at the same time using alternative methods of communication.

Nursing Intervention Post notice at nurses station and patients room about speech impairment. Provide special call bell if necessary. Provide alternative methods of communication, e.g., writing or felt board, pictures. Provide visual clues gestures, pictures, needs list, demonstration). Talk directly to patient, speaking slowly and distinctly. Use yes/no questions to begin with, progressing in complexity as patient responds.

Rationale

Evaluation

Allays anxiety related to inability to The patient was able to: communicate and fear that needs will not be met promptly. Call bell Established method that is activated by minimal of communication pressure is useful when patient is in which needs can unable to use regular call system. be expressed. Used resources Provides for communication of appropriately. needs/desires based on individual Practiced and situation/underlying deficit. implement speech therapy activities while at the same time using alternative methods of communication. Reduces confusion/anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word/idea association.

Assessment

Diagnosis

Planning

Nursing Intervention Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Talk without pressing for a response.

Rationale Patient is not necessarily hearing impaired, and raising voice may irritate or anger patient. Forcing responses can result in frustration and may cause patient to resort to automatic speech, e.g., garbled speech, obscenities. It is important for family members to continue talking to patient to reduce patients isolation, promote establishment of effective communication, and maintain sense of connectedness with family.

Evaluation

Encourage SO/visitors to persist in efforts to communicate with patient, e.g., reading mail, discussing family happenings even if patient is unable to respond appropriately. Respect patients preinjury capabilities; avoid speaking down to patient or making patronizing remarks.

Enables patient to feel esteemed, because intellectual abilities often remain intact.

4. Slurred speech

2. Difficulty of swallowing

Assessment Patient exhibits difficulty swallowing

Diagnosis Impaired swallowing secondary to stroke

Planning The patient will be able to: Demonstrate feeding methods appropriate to individual situation with aspiration prevented. Maintain desired body weight.

Nursing Intervention

Rationale

Evaluation The patient: Demonstrated feeding methods appropriate to individual situation with aspiration prevented. Maintained desired body weight.

Review individual pathology/ability to Nutritional interventions/choice of swallow, noting extent of paralysis; feeding route is determined by these clarity of speech; facial, tongue factors. involvement; ability to protect airway/ episodes of coughing or choking; presence of adventitious breath sounds; amount/character of oral secretions. Weigh periodically as indicated. Have suction equipment available at bedside, especially during early feeding efforts. Promote effective swallowing, e.g.: Schedule activities/medications to provide a minimum of 30 min rest before eating; Assist patient with head control/support, and position based on specific dysfunction; Timely intervention may limit amount/untoward effect of aspiration. Promotes optimal muscle function, helps to limit fatigue.

Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. Optimal positioning can facilitate intake/reduce risk of aspiration, e.g., head back for decreased posterior propulsion of tongue, head turned to weak side for unilateral pharyngeal paralysis, lying down on either side for reduced pharyngeal contraction.

2. Difficulty of swallowing

Assessment

Diagnosis

Planning

Nursing Intervention
Place patient in upright position during/after feeding as appropriate;

Rationale
Uses gravity to facilitate swallowing and reduces risk of aspiration. Increases salivation, improving bolus formation and swallowing effort. Aids in sensory retraining and promotes muscular control.

Evaluation

Serve foods at customary temperature and water always chilled;

Stimulate lips to close or manually open mouth by light pressure on lips/under chin, if needed; Feed slowly, allowing 3045 min for meals;

Feeling rushed can increase stress/level of frustration, may increase risk of aspiration, and may result in patients terminating meal early. Although use may strengthen facial and swallowing muscles, if patient lacks tight lip closure to accommodate straw or if liquid is deposited too far back in mouth, risk of aspiration may be increased. If swallowing efforts are not sufficient to meet fluid/nutrition needs, alternative methods of feeding must be pursued.

Limit/avoid use of drinking straw for liquids;

Maintain accurate I&O; record calorie count.

Assessment

Diagnosis

Planning

Nursing Intervention Assess extent of altered perception and related degree of disability. Determine Functional Independence Measure score.

Rationale Determination of individual factors aids in developing plan of care/choice of interventions and discharge expectations.

Evaluation

Ineffective coping related to situational crises vulnerability, cognitive perceptual changes as evidenced by inappropriate use of defense mechanisms, inability to cope/difficulty asking for help, change in usual communication patterns, inability to meet basic needs/role expectations, difficulty problem solving

The patient will be able to: - Verbalize acceptance of self in situation. - Talk/ communicate with SO about situation and changes that have occurred. - Verbalize awareness of own coping abilities. - Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.

The patient was be able to:

- Verbalize acceptance of self Identify meaning of the Independence/ability is highly valued in loss/dysfunction/change to American society but is not as significant in situation. - Talk/ patient. Note ability to in some other cultures. Some patients communicate understand events, provide accept and manage altered function with SO about realistic appraisal of situation. effectively with little adjustment, situation and whereas others have considerable difficulty recognizing and adjusting to changes that have deficits. In order to provide meaningful occurred. support and appropriate problem-solving, - Verbalize healthcare providers need to understand awareness of own the meaning of the stroke/limitations to coping abilities. patient. - Meet psychological Determine outside stressors, e.g., Helps identify specific needs, provides family, work, social, future opportunity to offer information/support needs as evidenced by nursing/healthcare needs. and begin problem-solving. appropriate Consideration of social factors, in addition to functional status, is important expression of in determining appropriate discharge feelings, destination. identification of options, and use Encourage patient to express Demonstrates acceptance of/assists of resources.
feelings, including hostility or anger, denial, depression, sense of disconnectedness. patient in recognizing and beginning to deal with these feelings.

3. Disturbed body image

Assessment

Diagnosis

Planning

Nursing Intervention Note whether patient refers to affected side as it or denies affected side and says it is dead.

Rationale Suggests rejection of body part/negative feelings about body image and abilities, indicating need for intervention and emotional support. Helps patient see that the nurse accepts both sides as part of the whole individual. Allows patient to feel hopeful and begin to accept current situation.

Evaluation

Acknowledge statement of feelings about betrayal of body; remain matter-of-fact about reality that patient can still use unaffected side and learn to control affected side. Use words (e.g., weak, affected, right-left) that incorporate that side as part of the whole body. Identify previous methods of dealing with life problems. Determine presence/quality of support systems. Support behaviors/efforts such as increased interest/participation in rehabilitation activities. 3. Disturbed body image

Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources.

Suggest possible adaptation to changes and understanding about own role in future lifestyle.

Assessment

Diagnosis

Planning

Nursing Intervention

Evaluation

Objective: >lethargic >BP: 180/100

Decreased Cardiac Output r/t malignant hypertension as manifested by decreased stroke volume.

Short term goal: After 8 hours of nursing interventions, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits.

Independent: Monitor BP every 1-2hours, or every 5 minutes during active titration of vasoactive drugs. Monitor ECG for dysrhythmias, conduction defects and for heart rate. Suggest frequent position changes. Encourage patient to decrease intake of caffeine, cola and chocolates

After 6 hours of nursing interventions, the client had no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Goal was met.-

5. Blood pressure of 180/100