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Nursing Care Plan For CVA Cerebrovascular Accident

Nursing-Care-Plan-For-CVA
-Cerebrovascular-Accident
Objective Data
Hemiparesis
Hemiplegia
Ataxia
Dysmetria
Facial droop
Paralysis
Aphasia
Dysphagia
Dysarthria
Vomiting
Increased secretions
Incontinence
LOC changes
Subjective Data
Numbness
Tingling
Decreased sensation
Difficulty swallowing
Headache
Pain
Nausea
Dizziness
Impaired Verbal Communication.
Inability to modulate speech, find and name words,
identify objects; inability to comprehend written/spoken language.
Inability to produce written communication
Desired Outcomes
Indicate an understanding of the
communication problems.
Establish method of communication in
which needs can be expressed.
Use resources appropriately.
Nursing Interventions
Listen for errors in conversation and
provide feedback.
Ask patient to follow simple commands
(“Close and open your eyes,” “Raise your
hand”); repeat simple words or sentences;
Point to objects and ask patient to name
them.
Have patient produce simple sounds
(“Dog,” “meow,” “Shh”).
Ask patient to write his name and a short
sentence. If unable to write, have patient
read a short sentence.
Write a notice at the nurses’ station and
patient’s room about speech impairment.
Provide a special call bell that can be
activated by minimal pressure if necessary.
Provide alternative methods of
communication: writing, pictures.
Talk directly to patient, speaking slowly and
distinctly. Phrase questions to be answered
simply by yes or no. Progress in complexity
as patient responds.
Speak in normal tones and avoid talking
too fast. Give patient ample time to
respond. Avoid pressing for a response.
Discuss familiar topics, e.g., weather, family,
hobbies, jobs.
Respect patient’s preinjury capabilities;
avoid “speaking down” to patient or
making patronizing remarks.
Consult and refer patient to speech
therapist.
Disturbed Sensory Perception
Poor concentration, altered thought processes/bizarre thinking
Inability to recognize/attach meaning to objects
Desired Outcomes
Regain/maintain usual level of
consciousness and perceptual functioning.
Acknowledge changes in ability and
presence of residual involvement.
Demonstrate behaviors to compensate
for/overcome deficits.
Nursing Interventions
Observe behavioral responses: crying,
inappropriate affect, agitation, hostility,
agitation, hallucination.
Eliminate extraneous noise and stimuli as
necessary.
Speak in calm, comforting, quiet voice,
using short sentences. Maintain eye
contact.
Ascertain patient’s perceptions. Reorient
patient frequently to environment, staff,
procedures.
Evaluate for visual deficits. Note loss of
visual field, changes in depth perception
(horizontal and/or vertical planes), presence
of diplopia (double vision).
Note inattention to body parts, segments
of environment, lack of recognition of
familiar objects/persons.
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author vip Fiona_
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.
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