Nursing Care Plans of a Patient With Stroke

7/27/2019 Nursing Care Plans of a Patient With Stroke

1/15

1. Left side body paralysis

Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Objective:

- Inability topurposefully

move withinthe physical

environment

- impairedcoordination;limited range

of motion

-decreased

musclestrength/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

musclestrength /

control

After 8 hours of

nursing

intervention the pt.

will:

- Maintain/increase

strength and

function of affected

or compensatorybody 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.

Assess functional

ability/extent of

impairment initially and

on a regular basis. Classify

according to 04 scale.

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 infunctional position; use

footboard during the

period of flaccid paralysis.

Maintain neutral position

of head.

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 dropand 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.

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 asevidenced by absence of

contractures, foot drop.

- Demonstrated

techniques/behaviors that

enable resumption of

activities.

-Maintained skin integrity.

Goal met.


2/15


3/15

1. Left side body paralysis


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 standingbalance (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.


4/15


5/15

4. Slurred speech


Objectives:

Slurred

speech

Impaired

verbalcommunication

related to

impairedcerebral

circulation;neuromuscular

impairment,

loss offacial/oral

muscletone/control;

generalized

weakness/fatigue

The patient will be

able to:

Establishmethod of

communication

in which needscan be

expressed.

Use resourcesappropriately.

Practice andimplementspeech therapy

activities while

at the same timeusing

alternativemethods of

communication.

Post notice at nurses

station and patientsroom about speech

impairment. Provide

special call bell ifnecessary.

Provide alternative

methods of

communication, e.g.,writing or felt board,

pictures. Providevisual clues gestures,

pictures, needs list,

demonstration).

Talk directly topatient, speaking

slowly and distinctly.

Use yes/no questionsto begin with,

progressing incomplexity as patient

responds.

Allays anxiety related to inability to

communicate and fear that needswill not be met promptly. Call bell

that is activated by minimal

pressure is useful when patient isunable to use regular call system.

Provides for communication of

needs/desires based on individual

situation/underlying deficit.

Reduces confusion/anxiety athaving to process and respond to

large amount of information at one

time. As retraining progresses,advancing complexity of

communication stimulates memoryand further enhances word/idea

association.

The patient was able to:

Established methodof communicationin which needs can

be expressed.

Used resourcesappropriately.

Practiced andimplement speech

therapy activitieswhile at the same

time usingalternative methods

of communication.


6/15


Speak in normal tones

and avoid talking toofast. Give patient

ample time to respond.

Talk without pressingfor a response.

Encourage SO/visitorsto persist in efforts tocommunicate with

patient, e.g., readingmail, discussing

family happenings

even if patient isunable to respond

appropriately.

Respect patientspreinjury capabilities;

avoid speakingdown to patient or

making patronizingremarks.

Patient is not necessarily hearing

impaired, and raising voice mayirritate or anger patient. Forcing

responses can result in frustration

and may cause patient to resort toautomatic speech, e.g., garbled

speech, obscenities.

It is important for family membersto continue talking to patient toreduce patients isolation, promote

establishment of effectivecommunication, and maintain sense

of connectedness with family.

Enables patient to feel esteemed,because intellectual abilities often

remain intact.


7/15

4. Slurred speech


8/15

2. Difficulty of swallowing


Patient

exhibitsdifficulty

swallowing

Impaired

swallowingsecondary to

stroke

The patient

will be able

to:

Demonstrate

feeding

methods

appropriate toindividual

situation with

aspiration

prevented.

Maintain

desired body

weight.

Review individual pathology/ability toswallow, noting extent of paralysis;clarity of speech; facial, tongueinvolvement; 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 atbedside, especially during earlyfeeding efforts.

Promote effective swallowing, e.g.:Schedule activities/medications to

provide a minimum of 30 min restbefore eating;

Assist patient with head

control/support, and position based onspecific dysfunction;

Nutritional interventions/choice offeeding route is determined by thesefactors.

Timely intervention may limitamount/untoward effect ofaspiration.

Promotes optimal muscle function,helps to limit fatigue.

Counteracts hyperextension, aiding

in prevention of aspiration andenhancing 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 unilateralpharyngeal paralysis, lying down oneither side for reduced pharyngealcontraction.

The patient:

Demonstrated

feeding methods

appropriate to

individual

situation with

aspirationprevented.

Maintained

desired body

weight.


9/15

2. Difficulty of swallowing


Place patient in upright positionduring/after feeding as appropriate;

Serve foods at customary temperatureand water always chilled;

Stimulate lips to close or manually

open mouth by light pressure onlips/under chin, if needed;

Feed slowly, allowing 3045 min for

meals;

Limit/avoid use of drinking straw forliquids;

Maintain accurate I&O; record caloriecount.

Uses gravity to facilitateswallowing and reduces risk ofaspiration.

Increases salivation, improvingbolus formation and swallowingeffort.

Aids in sensory retraining and

promotes muscular control.

Feeling rushed can increase

stress/level of frustration, mayincrease risk of aspiration, and mayresult in patients terminating mealearly.

Although use may strengthen facialand swallowing muscles, if patient

lacks tight lip closure toaccommodate straw or if liquid isdeposited too far back in mouth,risk of aspiration may be increased.

If swallowing efforts are notsufficient to meet fluid/nutritionneeds, alternative methods offeeding must be pursued.


10/15


11/15


Ineffectivecoping relatedto situational

crises

vulnerability,cognitive

perceptualchanges as

evidenced by

inappropriate

use of defensemechanisms,inability to

cope/difficulty

asking for help,change in usual

communicationpatterns,inability to meet

basic needs/role

expectations,difficulty

problem solving

The patientwill be able to:

- Verbalize

acceptance ofself in

situation.- Talk/

communicate

with SO about

situation andchanges thathave occurred.

- Verbalize

awareness ofown coping

abilities.- Meetpsychological

needs as

evidenced byappropriate

expression offeelings,

identification

of options, anduse of

resources.

Assess extent of alteredperception and related degree of

disability. Determine FunctionalIndependence Measure score.

Identify meaning of theloss/dysfunction/change to

patient. Note ability tounderstand events, providerealistic appraisal of situation.

Determine outside stressors, e.g.,family, work, social, futurenursing/healthcare needs.

Encourage patient to expressfeelings, including hostility oranger, denial, depression, sense

of disconnectedness.

Determination of individual factors aidsin developing plan of care/choice of

interventions and discharge expectations.

Independence/ability is highly valued inAmerican society but is not as significantin some other cultures. Some patientsaccept and manage altered functioneffectively with little adjustment,whereas others have considerable

difficulty recognizing and adjusting todeficits. In order to provide meaningfulsupport and appropriate problem-solving,healthcare providers need to understandthe meaning of the stroke/limitations to

patient.

Helps identify specific needs, providesopportunity to offer information/supportand begin problem-solving.

Consideration of social factors, in

addition to functional status, is importantin determining appropriate discharge

destination.

Demonstrates acceptance of/assistspatient in recognizing and beginning todeal with these feelings.

The patient wasbe able to:

- Verbalize

acceptance of selfin situation.

- Talk/communicate

with SO about

situation and

changes that haveoccurred.- Verbalize

awareness of own

coping abilities.- Meet

psychologicalneeds asevidenced by

appropriate

expression offeelings,

identification ofoptions, and use

of resources.


12/15

3. Disturbed body image


13/15

3. Disturbed body image


Note whether patient refersto affected side as it ordenies affected side and says

it is dead.

Acknowledge statement offeelings about betrayal of

body; remain matter-of-factabout reality that patient can

still use unaffected side andlearn to control affected side.Use words (e.g., weak,

affected, right-left) thatincorporate 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 increasedinterest/participation inrehabilitation activities.

Suggests rejection of bodypart/negative feelings about bodyimage and abilities, indicating need

for intervention and emotional

support.

Helps patient see that the nurseaccepts both sides as part of the

whole individual. Allows patient to

feel hopeful and begin to accept

current situation.

Provides opportunity to usebehaviors previously effective, build

on past successes, and mobilize

resources.

Suggest possible adaptation to

changes and understanding about

own role in future lifestyle.


14/15

Assessment Diagnosis Planning Nursing Intervention Evaluation


15/15

5. Blood pressure of 180/100

Objective:

>lethargic

>BP: 180/100

Decreased Cardiac

Output r/t malignanthypertension as

manifested bydecreased stroke

volume.

Short term goal:

After 8 hours of

nursing interventions,the client will have no

elevation in bloodpressure above normal

limits and will

maintain bloodpressure within

acceptable limits.

Independent:

Monitor BP every 1-2hours, or every

5 minutes during active titration ofvasoactive drugs.

Monitor ECG for dysrhythmias,

conduction defects and for heart rate.

Suggest frequent position changes.

Encourage patient to decrease intakeof caffeine, cola and chocolates

After 6 hours of nursing

interventions, the clienthad no elevation in

blood pressure abovenormal limits and will

maintain blood pressurewithin acceptable

limits.

Goal was met.-

Documents

Nursing Care Plans of a Patient With Stroke