NURSING CARE PLAN ASSIGNMENT Hemorrhagic Stroke Cerebrovascular Accident

NURSING CARE PLAN ASSIGNMENT Hemorrhagic Stroke Cerebrovascular Accident (CVA) or stroke as widely known or brain attack according to Doenges et al., 2010, is an injury or death to parts of the brain due to a break in the blood supply to that area causing impairment, like paralysis or speech impairment. Furthermore, There are types of stroke and one of them is HEMORRHAGIC STROKE which is a result of a rupture of blood vessel wall causing bleeding into the brain leading to squeezing of the brain tissue. According to Morrison, 2007, hemorrhagic stroke accounts for approximately 15 to 20 of CVA, with only 20 of patients regaining functional independence (Nassisi, 2008). Impaired Physical ActivityAssessment Possibly evidenced by Inability to move in the physical environment Impaired coordination Limited activities and/or range of motion Diminished muscle strength and controlGoals/Evaluation Criteria-Patient will be able to Maintain or improve strength and function of the patients affected body part. Avoid contractures and footdrop by keeping bodys normal function Demonstrate methods and actions on restarting activities of daily living Keep the skin intactInterventionsRationaleAssess patients functional capability and the degree of injury. To be able to distinguish the strengths and deficiencies which can be helpful in determining the appropriate treatment.Repositioning patient every 2 hours and as neededTo decrease the risk for skin breakdown and incidence of pressure ulcers especially on the affected side of the body.Prone position as toleratedThis position will help client to maintain a functional hip extension.Keep the extremities in normal anatomical position by using equipment like footboardTo prevent further musculoskeletal injury like contractures of muscles and foot drop.Provide arm sling when client is in upright position or sitting.To prevent shoulder injury especially on affected sideDetermine the use of and need for positional aids and splints during spastic paralysisFlexion contractures occur because flexor muscles are stronger than extensors.Place pillow under axilla to abduct arm.To Prevents adduction of shoulder and flexion of elbow.Elevate arm and hand with a pillowThis will Improve circulation and will prevent swellingPlace hard hand-rolls in the palm with fingers and thumb opposed.To maintain the fingers in their functional positionMaintain knee and hip in extended position.To keep the bodys anatomical and functional position.Using a trochanter roll, keep the leg in neutral positionTo prevent hip injury like external hip rotation.Watch out for signs of circulation changes like discoloration and swelling.Affected side especially if neglected by the patient is at high risk for skin breakdown and impede circulationRegularly assess and monitor skin especially on bony prominencesBony prominences are high risk for pressure ulcer development especially on the affected body partsGently massage the affected side of the body as needed and as necessaryTo stimulate the affected body area and promote circulation preventing skin injury.Encouraged passive and active Range of Motion exercises as toleratedto prevent musculoskeletal complications like contractures and atrophy and to promote blood circulation as well.Help the client to assume a sitting position and gain balance by elevating the head of the bed, assisting patient to sit on the bed edge while using the good and strong extremities to support body weight.To improve patients musculoskeletal strength and maximize patients functional ability.Once the vital signs are stable, get the client up in the chair as soon as possible as tolerated.Increase body activity promotes physical and systemic recovery and prevents complications. Provide seat cushion and assist in weight shifting frequently. To Reduce pressure on the coccyx and prevents skin breakdown.Set goals with client/significant other (SO) for increasing participation in activities, exercise, and position changesThis promotes patient centered care and provides involvement, control and independence.Encourage client to assist with movement and exercises using the good extremity to support and move weaker side.To promote recognition of the affected side and prevention of neglect on that body part and to promote involvement in care, rehabilitation and recovery.When available, provide specialized bed, like water bed or bed with egg crate mattress. To promote circulation prevent skin breakdown and injuryPhysical therapist consultation about active, resistive exercises and client ambulation.Individualized program and patient centered care program in order to meet particular needs and deal with deficits in balance, coordination, and strength.Administer muscle relaxants and antispasmodics as indicated and as ordered, such as baclofen and dantrolene.To relieve spasticity in affected extremities. Unilateral NeglectAssessment Possibly evidenced by Inabillity and failure to move eyes, head, limbs, trunk in the neglected side despite being aware of a stimulus in that space Appears unaware of positioning of neglected limbs Lack of safety precautions with regard to the neglected side Failure to eat food from left side of plate and dress or groom neglected side Failure to notice people approaching from neglected sideGoal/Evaluation Criteria-Client will be able to Acknowledge presence of impairment.InterventionsRationaleReiterate to the patient about the disability and dysfunctionTo Promote acknowledgement of the impairment and promotes cooperation in the goal of treatment and rehabilitation.Instruct and educate the client and family in treatment and management techniques and method centered on training attention on the neglected sideTo Promote involvement of all individuals especially the patient himself in addressing the problem, which may enhance and improve recovery.Approach client from unaffected side.To enhance clients awareness and promotes interaction.Encourage client to turn head and eyes to scan the environment and surroundings.To increase awareness to environment.Discuss affected body side while touching, manipulating, and massaging affected side and provide items of varied size, weight, and texture for client to hold.To Provides tactile stimulation and to encourage acknowledgment of the impaired body side.Have client look at and handle affected side as toleratedTo encourage client to accept affected limb or side as part of self even though it does not feel like it belongs.Assist client to position affected extremity carefully and to routinely It Promotes safety awareness, acknowledgement of impairment and reducing risk of injury.Instruct SO/caregiver to assess extremitys position and alignmentTo prevent pressure injuries and prevent further skin breakdown.Discuss environmental safety concerns and identify possible hazards and assist in making plan to correct risk factors.According to (Barrett John, 2007), Patient may continue to have some ongoing degree of functional impairment, including difficulty with navigating in familiar environments Reinforce and reiterate continuation of prescribed rehabilitation activities and exercises and neuropsychological therapies, as indicated and as needed.To Maximize recovery and enhance independence. (Barrett John, 2007). Reference Doenges, M., Moorhouse, M., Murr, A. (2010). Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span (8th ed.). Philadelphia, PADavis. Y, B8L 1(IzZYrH9pd4n(KgVB,lDAeX)Ly5otebW3gpj/gQjZTae9i5j5fE514g7vnO( ,[email protected] /[email protected] 6Q