Nursing Care Plan For CVA Cerebrovascular Accident
Based on the assessment data, the major nursing diagnoses for a patient with stroke may include the following: Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury.
Similar Mind Maps
Disturbed Sensory PerceptionPoor concentration, altered thought processes/bizarre thinkingInability to recognize/attach meaning to objects
Regain/maintain usual level ofconsciousness and perceptual functioning.
Acknowledge changes in ability andpresence of residual involvement.
Demonstrate behaviors to compensatefor/overcome deficits.
Observe behavioral responses: crying,inappropriate affect, agitation, hostility,agitation, hallucination.
Eliminate extraneous noise and stimuli asnecessary.
Speak in calm, comforting, quiet voice,using short sentences. Maintain eyecontact.
Ascertain patient’s perceptions. Reorientpatient frequently to environment, staff,procedures.
Evaluate for visual deficits. Note loss ofvisual field, changes in depth perception(horizontal and/or vertical planes), presenceof diplopia (double vision).
Note inattention to body parts, segmentsof environment, lack of recognition offamiliar objects/persons.
Impaired Verbal Communication. Inability to modulate speech, find and name words,identify objects; inability to comprehend written/spoken language.Inability to produce written communication
Indicate an understanding of thecommunication problems.
Establish method of communication inwhich needs can be expressed.
Use resources appropriately.
Listen for errors in conversation andprovide feedback.
Ask patient to follow simple commands(“Close and open your eyes,” “Raise yourhand”); repeat simple words or sentences;
Point to objects and ask patient to namethem.
Have patient produce simple sounds(“Dog,” “meow,” “Shh”).
Ask patient to write his name and a shortsentence. If unable to write, have patientread a short sentence.
Write a notice at the nurses’ station andpatient’s room about speech impairment.Provide a special call bell that can beactivated by minimal pressure if necessary.
Provide alternative methods ofcommunication: writing, pictures.
Talk directly to patient, speaking slowly anddistinctly. Phrase questions to be answeredsimply by yes or no. Progress in complexityas patient responds.
Speak in normal tones and avoid talkingtoo fast. Give patient ample time torespond. Avoid pressing for a response.
Discuss familiar topics, e.g., weather, family,hobbies, jobs.
Respect patient’s preinjury capabilities;avoid “speaking down” to patient ormaking patronizing remarks.
Consult and refer patient to speechtherapist.