care plan for stroke

Get Started. It's Free
or sign up with your email address
care plan for stroke by Mind Map: care plan for stroke

1. Ineffective Cerebral Tissue Perfusion rt Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vaso­spasm, cerebral edema evidenced by Altered level of consciousness; memory loss Changes in motor/sensory responses; restlessness Sensory, language, intellectual, and emotional deficits Changes in vital signs

1.1. Desired Outcomes

1.1.1. Maintain usual/improved level of consciousness, cognition, and motor/sensory function.

1.1.2. Demonstrate stable vital signs and absence of signs of increased ICP.

1.1.3. Display no further deterioration/recurrence of deficits

1.2. Nursing Interventions

1.2.1. Assess factors related to individual situation for decreased cerebral perfusion and potential for increased ICP.

1.2.2. Closely assess and monitor neurological status frequently and compare with baseline.

1.2.3. Monitor vital signs: changes in blood pressure, compare BP readings in both arms. Heart rate and rhythm, assess for murmurs. Respirations, noting patterns and rhythm (periods of apnea after hyperventilation), Cheyne-Stokes respiration.

1.2.4. Evaluate pupils, noting size, shape, equality, light reactivity.

1.2.5. Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.

1.2.6. Assess higher functions, including speech, if patient is alert.

1.2.7. Position with head slightly elevated and in neutral position.

1.2.8. Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures.

1.2.9. Prevent straining at stool, holding breath.

1.2.10. Administer supplemental oxygen as indicated.

1.2.11. Administer medications as indicated: Alteplase (Activase), t-PA; Anticoagulants:Antiplatelet agents,Antifibrinolytics.Antihypertensives..Phenytoin ..Stool softeners.

1.2.12. Monitor laboratory studies as indicated: prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) time, Dilantin level.

2. Impaired Physical Mobility rt Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis Perceptual/cognitive impairment evidenced by Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control

2.1. Desired Outcomes

2.1.1. Maintain/increase strength and function of affected or compensatory body part.

2.1.2. Maintain optimal position of function as evidenced by absence of contractures, foot drop.

2.1.3. Demonstrate techniques/behaviors that enable resumption of activities.

2.1.4. Maintain skin integrity.

2.2. Nursing Interventions

2.2.1. Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale.

2.2.2. Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side.

2.2.3. Position in prone position once or twice a day if patient can tolerate.

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

2.2.5. Use arm sling when patient is in upright position, as indicated.

2.2.6. Evaluate need for positional aids and/or splints during spastic paralysis:

2.2.7. Place pillow under axilla to abduct arm

2.2.8. Elevate arm and hand

2.2.9. Place hard hand-rolls in the palm with fingers and thumb opposed.

2.2.10. Discontinue use of footboard, when appropriate.

2.2.11. Observe affected side for color, edema, or other signs of compromised circulation.

2.2.12. Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary.

2.2.13. Provide egg-crate mattress, water bed, flotation device, or specialized beds, as indicated.

3. Impaired Verbal Communication rt Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue evidenced by Impaired articulation; does not/cannot speak (dysarthria) Inability to modulate speech, find and name words, identify objects; inability to comprehend written/spoken language Inability to produce written communication

3.1. Desired Outcomes

3.1.1. Indicate an understanding of the communication problems.

3.1.2. Establish method of communication in which needs can be expressed.

3.1.3. Use resources appropriately.

3.2. Nursing Interventions

3.2.1. Assess extent of dysfunction: patient cannot understand words or has trouble speaking or making self understood. Differentiate aphasia from dysarthria.

3.2.2. Listen for errors in conversation and provide feedback.

3.2.3. Ask patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat simple words or sentences;

3.2.4. Point to objects and ask patient to name them.

3.2.5. Have patient produce simple sounds (“Dog,” “meow,” “Shh”).

3.2.6. Ask patient to write his name and a short sentence. If unable to write, have patient read a short sentence.

3.2.7. 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.

3.2.8. Provide alternative methods of communication: writing, pictures.

3.2.9. Talk directly to patient, speaking slowly and distinctly. Phrase questions to be answered simply by yes or no. Progress in complexity as patient responds.

3.2.10. Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoid pressing for a response.

3.2.11. Discuss familiar topics, e.g., weather, family, hobbies, jobs.

3.2.12. Respect patient’s preinjury capabilities; avoid “speaking down” to patient or making patronizing remarks.

3.2.13. Consult and refer patient to speech therapist.

4. Subjective Data:

4.1. Numbness

4.2. Tingling

4.3. Decreased sensation

4.4. Difficulty swallowing

4.5. Headache

4.6. Pain

4.7. Nausea

4.8. Dizziness

5. Objective Data:

5.1. Hemiparesis

5.2. Hemiplegia

5.3. Ataxia

5.4. Dysmetria

5.5. Facial droop

5.6. Paralysis

5.7. Aphasia

5.8. Dysphagia

5.9. Dysarthria

5.10. Vomiting

5.11. Increased secretions

5.12. Incontinence

5.13. LOC changes

6. Disturbed Sensory Perception rt Altered sensory reception, transmission, integration (neurological trauma or deficit) Psychological stress (narrowed perceptual fields caused by anxiety) evidenced by Disorientation to time, place, person Change in behavior pattern/usual response to stimuli; exaggerated emotional responses Poor concentration, altered thought processes/bizarre thinking Reported/measured change in sensory acuity: hypoparesthesia; altered sense of taste/smell Inability to tell position of body parts (proprioception) Inability to recognize/attach meaning to objects (visual agnosia) Altered communication patterns Motor incoordination

6.1. Desired Outcomes

6.1.1. Regain/maintain usual level of consciousness and perceptual functioning.

6.1.2. Acknowledge changes in ability and presence of residual involvement.

6.1.3. Demonstrate behaviors to compensate for/overcome deficits.

6.2. Nursing Interventions

6.2.1. Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation, hallucination.

6.2.2. Establish and maintain communication with the patient. Set up a simple method of communicating basic needs. Remember to phrase your questions so he’ll be able to answer using this system. Repeat yourself quietly and calmly and use gestures when necessary to help in understanding.

6.2.3. Eliminate extraneous noise and stimuli as necessary.

6.2.4. Speak in calm, comforting, quiet voice, using short sentences. Maintain eye contact.

6.2.5. Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, procedures.

6.2.6. Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal and/or vertical planes), presence of diplopia (double vision).

6.2.7. Note inattention to body parts, segments of environment, lack of recognition of familiar objects/persons.