Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Nursing Intervention for Stroke

Stroke or cerebrovascular accident (CVA) or brain attack, is when poor blood flow to the brain results in cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic due to bleeding.

Symptoms of Stroke
  • Sudden numbness or weakness of the face, arm or leg (especially on one side of the body)
  • Sudden confusion, trouble speaking or understanding speech
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden severe headache with no known cause

Nursing Diagnosis and Nursing Intervention for Stroke
  1. Ineffective cerebral tissue perfusion related to brain hemorrhage, edema

    Goal :
    Adequate tissue perfusion with indicators: Adequate tissue perfusion is based on peripheral pulse pressure, skin warmth, adequate urine output.

    Plan of action :
    • Monitor neurologic status
      R /: Knowing the tendency of the level of awareness and potential increase in intra-cranial pressure and know the location. Area and progress damage the central nervous system.
    • Monitor respiratory status
      R: / Respiratory irregularity can give the location of the damage / increase in intra-cranial pressure.
    • Monitor heart sound
      R /: Bradycardia may occur as a result of brain damage.
    • Place the head with a slightly elevated position and in a neutral position
      R /: Lowering arterial pressure to improve drainage and improve circulation
    • Manage medications
      R /: Prevention / treatment reduction intra-cranial pressure.
    • Give Oxygen as indicated
      R /: Reducing hypoxia.

  2. Impaired physical mobility related to decreased muscle strength

    Outcome :
    • The joints are not stiff
    • There was no muscle atrophy

    Plan of action :
    1. Exercise therapy
      Joint mobility
      • Explain to the patient and the patient's family, the purpose of joint movement exercises.
      • Monitor the location and discomfort during exercise
      • Use a loose-fitting clothing
      • Assess the ability of patients to the movements
      • Encourage active ROM
      • Teach ROM active / passive on the patient and patient's family.
      • Change the position of the patient every 2 hours.
      • Assess progress / advancement training.
    2. Self Care Assistance
      • Monitor the independence of patients
      • Assist the patient in terms of self-care: eating, bathing, toileting.
      • Teach family in the fulfillment of self-care patients.
      The movement of the active / passive aims to maintain flexibility of joints
      Physical disability and psychological patient, can reduce the daily personal care and can be fulfilled with the help of personal hygiene for patients can be maintained.

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