Assessment

Diagnosis

Planning

Nursing Intervention
Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 0–4 scale.

Rationale
Identifies strengths/deficiencies and may provide information regarding recovery. Assists in choice of interventions, because different techniques are used for flaccid and spastic paralysis. Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus. Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe. Prevents contractures/foot drop and facilitates use when/if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.

Evaluation

Objective:

- Inability to purposefully move within the physical environment - impaired coordination; limited range of motion -decreased muscle strength/cont rol

Impaired Physical Mobility related to paresis as evidenced by inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength / control

After 8 hours of nursing intervention the pt. will:
- Maintain/increase strength and function of affected or compensatory body part. - Maintain optimal position of function as evidenced by absence of contractures, foot drop. - Demonstrate techniques / behaviors that enable resumption of activities. - Maintain skin integrity.

After 8 hours of nursing intervention the pt. has: - Maintained/increased strength and function of affected or compensatory body part. - Maintained optimal position of function as evidenced by absence of contractures, foot drop. - Demonstrated techniques/behaviors that enable resumption of activities. -Maintained skin integrity. Goal met. 

Change positions at least every 2 hrs. (Supine, side lying) and possibly more often if placed on affected side. Position in prone position once or twice a day if patient can tolerate.

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

1. Left side body paralysis

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assist to sit on edge of bed. support patient’s lower back with hands while positioning own knees outside patient’s knees. Encourage patient to assist with movement and exercises using unaffected extremity to support/move weaker side.g.1. raise head of bed.. assist in using parallel bars/walkers).. enhancing proprioception and motor response. Aids in retraining neuronal pathways. put flat walking shoes on patient. Left side body paralysis Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation Assist to develop sitting balance (e.g. increase sitting time) and standing balance (e. . May respond as if affected side is no longer part of body and needs encouragement and active training to “reincorporate” it as a part of own body. having patient use the strong arm to support body weight and strong leg to move affected leg.

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Nursing Intervention Post notice at nurses’ station and patient’s room about speech impairment. “needs” list.. implement speech therapy activities while at the same time using alternative methods of communication. speaking slowly and distinctly. Rationale Evaluation   Allays anxiety related to inability to The patient was able to: communicate and fear that needs will not be met promptly. demonstration). As retraining progresses. Provide visual clues gestures. Call bell  Established method that is activated by minimal of communication pressure is useful when patient is in which needs can unable to use regular call system. . pictures.  Used resources Provides for communication of appropriately. Provide alternative methods of communication. needs/desires based on individual  Practiced and situation/underlying deficit. loss of facial/oral muscle tone/control. writing or felt board.g. Slurred speech Assessment Objectives: Slurred speech Diagnosis Impaired verbal communication related to impaired cerebral circulation. Provide special call bell if necessary. advancing complexity of communication stimulates memory and further enhances word/idea association. pictures. Practice and implement speech therapy activities while at the same time using alternative methods of communication. e. Talk directly to patient. Reduces confusion/anxiety at having to process and respond to large amount of information at one time. Use yes/no questions to begin with.4. Use resources appropriately. progressing in complexity as patient responds. be expressed. neuromuscular impairment. generalized weakness/fatig ue Planning The patient will be able to:  Establish method of communication in which needs can be expressed.

. discussing family happenings even if patient is unable to respond appropriately. and maintain sense of connectedness with family.g. Enables patient to feel esteemed. Evaluation Encourage SO/visitors to persist in efforts to communicate with patient. Respect patient’s preinjury capabilities. e. because intellectual abilities often remain intact. Forcing responses can result in frustration and may cause patient to resort to “automatic” speech. promote establishment of effective communication.. e. avoid “speaking down” to patient or making patronizing remarks. Rationale Patient is not necessarily hearing impaired.. obscenities.g. garbled speech. It is important for family members to continue talking to patient to reduce patient’s isolation. Talk without pressing for a response. Give patient ample time to respond.Assessment Diagnosis Planning Nursing Intervention Speak in normal tones and avoid talking too fast. and raising voice may irritate or anger patient. reading mail.

4. Slurred speech .

Difficulty of swallowing Assessment Patient exhibits difficulty swallowing Diagnosis Impaired swallowing secondary to stroke Planning The patient will be able to: Demonstrate feeding methods appropriate to individual situation with aspiration prevented. Assist patient with head control/support. Promote effective swallowing. lying down on either side for reduced pharyngeal contraction. tongue factors. Nursing Intervention Rationale Evaluation The patient: Demonstrated feeding methods appropriate to individual situation with aspiration prevented.. Counteracts hyperextension. presence of adventitious breath sounds. and position based on specific dysfunction. amount/character of oral secretions. head back for decreased posterior propulsion of tongue. Timely intervention may limit amount/untoward effect of aspiration. aiding in prevention of aspiration and enhancing ability to swallow. Have suction equipment available at bedside. facial. ability to protect airway/ episodes of coughing or choking.: Schedule activities/medications to provide a minimum of 30 min rest before eating. Promotes optimal muscle function.g. helps to limit fatigue. noting extent of paralysis. involvement. Weigh periodically as indicated. e. Review individual pathology/ability to Nutritional interventions/choice of swallow. Maintain desired body weight.g. feeding route is determined by these clarity of speech. .2. especially during early feeding efforts. Optimal positioning can facilitate intake/reduce risk of aspiration. head turned to weak side for unilateral pharyngeal paralysis. Maintained desired body weight. e.

and may result in patient’s terminating meal early. . may increase risk of aspiration. Feed slowly. if needed. record calorie count. Difficulty of swallowing Assessment Diagnosis Planning Nursing Intervention Place patient in upright position during/after feeding as appropriate. improving bolus formation and swallowing effort. Evaluation Serve foods at customary temperature and water always chilled. Increases salivation. allowing 30–45 min for meals. Rationale Uses gravity to facilitate swallowing and reduces risk of aspiration. Maintain accurate I&O. Aids in sensory retraining and promotes muscular control. if patient lacks tight lip closure to accommodate straw or if liquid is deposited too far back in mouth. risk of aspiration may be increased. Although use may strengthen facial and swallowing muscles. If swallowing efforts are not sufficient to meet fluid/nutrition needs.2. Limit/avoid use of drinking straw for liquids. Stimulate lips to close or manually open mouth by light pressure on lips/under chin. alternative methods of feeding must be pursued. Feeling rushed can increase stress/level of frustration.

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Meet psychological needs as evidenced by appropriate expression of feelings. future opportunity to offer information/support needs as evidenced by nursing/healthcare needs. Note ability to in some other cultures. provides family. denial. support and appropriate problem-solving. cognitive perceptual changes as evidenced by inappropriate use of defense mechanisms. is important expression of in determining appropriate discharge feelings.Verbalize acceptance of self Identify meaning of the Independence/ability is highly valued in loss/dysfunction/change to American society but is not as significant in situation. including hostility or anger. and begin problem-solving. sense of disconnectedness. and use Encourage patient to express Demonstrates acceptance of/assists of resources.Talk/ patient. appropriate Consideration of social factors.Verbalize healthcare providers need to understand awareness of own the meaning of the stroke/limitations to coping abilities.Verbalize awareness of own coping abilities. e.Verbalize acceptance of self in situation. social. . inability to cope/difficulty asking for help. Helps identify specific needs. . destination.g. effectively with little adjustment. The patient was be able to: .Meet psychological Determine outside stressors. .. in addition to functional status. . Rationale Determination of individual factors aids in developing plan of care/choice of interventions and discharge expectations. identification of options. patient in recognizing and beginning to deal with these feelings. inability to meet basic needs/role expectations.Talk/ communicate with SO about situation and changes that have occurred. and use of resources. . work.Assessment Diagnosis Planning Nursing Intervention Assess extent of altered perception and related degree of disability. provide accept and manage altered function with SO about realistic appraisal of situation. identification of options. In order to provide meaningful occurred. . change in usual communication patterns. situation and whereas others have considerable difficulty recognizing and adjusting to changes that have deficits. Determine Functional Independence Measure score. depression. Evaluation Ineffective coping related to situational crises vulnerability. Some patients communicate understand events. . difficulty problem solving The patient will be able to: . patient. feelings.

Disturbed body image .3.

Disturbed body image Provides opportunity to use behaviors previously effective. Support behaviors/efforts such as increased interest/participation in rehabilitation activities. Helps patient see that the nurse accepts both sides as part of the whole individual.g. Suggest possible adaptation to changes and understanding about own role in future lifestyle.Assessment Diagnosis Planning Nursing Intervention Note whether patient refers to affected side as “it” or denies affected side and says it is “dead. .” Rationale Suggests rejection of body part/negative feelings about body image and abilities. Determine presence/quality of support systems. build on past successes. Identify previous methods of dealing with life problems. Evaluation Acknowledge statement of feelings about betrayal of body. right-left) that incorporate that side as part of the whole body. affected. indicating need for intervention and emotional support. remain matter-of-fact about reality that patient can still use unaffected side and learn to control affected side. Allows patient to feel hopeful and begin to accept current situation. and mobilize resources.. weak. 3. Use words (e.

Assessment Diagnosis Planning Nursing Intervention Evaluation .

↑ Blood pressure of 180/100 . cola and chocolates After 6 hours of nursing interventions. conduction defects and for heart rate.- 5.Objective: >lethargic >BP: 180/100 Decreased Cardiac Output r/t malignant hypertension as manifested by decreased stroke volume. Short term goal: After 8 hours of nursing interventions. the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Encourage patient to decrease intake of caffeine. Suggest frequent position changes. Monitor ECG for dysrhythmias. or every 5 minutes during active titration of vasoactive drugs. Independent: Monitor BP every 1-2hours. the client had no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Goal was met.