The NIH stroke scale should be performed as frequently as needed (every 15 minutes to once a shift depending on patient status) to monitor neurological status and progression of stroke Perform the NIHSS to monitor for worsening of stroke symptoms Thrombolytics dissolve the clot and must be started within 4.5 hours of symptoms startingEndovascular procedures include clot retrieval or delivering thrombolytics directly to the site of the clot If an ischemic stroke is confirmed, anticipate starting thrombolytics or preparing for an endovascular procedure If a hemorrhagic stroke is confirmed, prepare the patient for surgeryĪ hemorrhagic stroke can be treated by surgery, clipping, or coiling to stop the bleeding and relieve pressure in the brain Long-term goal: The patient will return to baseline and experience no residual neurological dysfunction CVA/Stroke Nursing Interventions with Rationales – Ineffective cerebral tissue perfusion Nursing Interventions Short-term goal: By the end of the shift the patient will demonstrate an improvement in speaking ability and demonstrate equal bilateral motor strength. Ineffective cerebral tissue perfusion related to hemorrhage or clot in a cerebral vessel as evidenced by right-sided weakness, facial asymmetry, and difficulty speaking Goal/Desired Outcome CT scan confirms the presence of a cerebral infarction.The patient has right-sided weakness, facial asymmetry, and difficulty speaking.The patient is unable to verbally communicate.#1 CVA/Stroke Nursing Care Plan – Ineffective cerebral tissue perfusion CVA/Stroke Nursing Assessment The patient is admitted to the hospital for a Cerebrovascular Accident (CVA/Stroke). A CT scan of the head is performed, confirming the presence of cerebral infarction. The patient’s blood work is within normal limits. Her gaze is normal and partial hemianopia is noted in the right visual field. She can smile and raise her eyebrows, but her face is asymmetrical and the right side is less mobile than the left. She is unable to answer orientation questions and engages in endless word-searching, repeating sentences such as – “you… the… the…” The patient is able to obey commands on the left side, but can only minimally move her right arm and leg. Upon assessment, the patient appears drowsy. The patient’s son also noticed her face appeared asymmetrical. When he asked his mom what was wrong, she had difficulty finding words and was unable to properly formulate sentences. The patient’s son said he was having lunch with his mom when she began having problems holding her fork and using her right arm. Cerebrovascular Accident (CVA/Stroke) Case ScenarioĪ 73-year old female presents to the ED with complaints of right-sided weakness and difficulty speaking. It will include three CVA/Stroke nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, and nursing interventions with rationales. Here we will formulate sample cerebrovascular accident (CVA/Stroke) nursing care plans based on a hypothetical case scenario.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |