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Nursing Care Plan CVA

Nursing Care Plan CVA

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Published by hermesdave1
NCP
NCP

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Published by: hermesdave1 on Oct 19, 2009
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07/08/2013

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29.
Nursing Care Plan
(Impaired Verbal Communication)
CuesNursinDiagnosisScientific ExplanationObjective/ Planning ImplementationRationaleExpecteOutcome
Subjective:“Nahihirapansiyang magsalita,kung minsanumuungol din siya,as verbalized byMr. D’s wife.”Objective:Received pt. onlying position onbed, unconscious ,with ongoing PNSS1L regulated @ 10-15 gtts./min. (KVO)200 ml. levelinfusing well @ lefthand.
(+) difficultyin speaking
(+)weakness
(+)headacheImpaired verbalcommunicationrelated toimpairedcerebralcirculationpossiblyevidence byimpairedarticulation.Difficulty inspeakingfunction resultingfrom injury of thebrain centers. Itmay involveimpairment of ability to readand write as wellas to speak,comprehend andunderstandgestures bec. of the damage of the lefthemisphere of the brain isaffected andwhere theBroca’s arealocated (principalspeech center).
Plan:
After the provisionof nursing care, thesignificant otherswill verbalizeunderstandingabout the disease.
Short Term:
After 3 hrs. of N.Ithe client willestablish methodsof communication inwhich needs can beexpressed.Maintain eyecontactcommunication.Establish rapport.Monitor and recordV/S.Establish goodrelationship,listening carefullyand attending toclient’s verbal andnon-verbalexpressions.To build trustingrelationship.To have baselinedata.To maintain goodcommunicationskills with thepatient.
Short Term:
After 3 hrs. of N.Ithe client shall beable to improvedcommunicationabilities andimproved familycopping.
 
(+)dizziness
(+) blurredvision
(+)Paralysison right partof the body
With NGTinserted
With Foleycatheter insertedVital Signs:BP: 140/100 mmHgKeepcommunicationsimple, using allmodes of accessinginformation, visualauditory andkinesthetic.Validate themeaning of non-verbalcommunication.Be honest if youdon’t understand,seek assistancefrom others.Plan for alternativemethod of communicationincorporatedinformation abouttype of disabilitypresent.Reinforce that lossof speech doesnot imply that lossof intelligence.Assist the pt.’sneed to establishmeans of communicating.Makingassumption to theword maybewrong.Using aids incommunicatingpromote learningand recovery.To limit self-pityand depression.To give right
 
Long Term:
After 3 days of N.Ithe client will beable to participatein therapeuticcommunication.Maintain goodenvironment.Enhanceparticipation andcommunicationplan.Provide sufficienttime for client torespond.Use confrontationskills, whenappropriate, withinan establishnurse-clientrelationship. Provideenvironmentalstimuli as neededor educe stimuli.Involve SO/ familyin plan of care asmuch as possible.manner whencommunicating.To clarifydiscrepanciesbetween verbaland non-verbalcues.To maintaincontact with realityand to lessen theanxiety that mayworsen theproblem.To help the pt.recover from hiscondition and limitdeterioration.To help the pt. in
Long Term:
After 3 days of N.Ithe pt. shall beable to indicate anunderstanding of the communicationdifficulty and plansfor ways of handling.

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