NCP: CVA 1.

Impaired Physical Mobility

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Assessment

O> Limited range of motion (client cant fully extend his right arm and hold up his right shoulder) Limited ability and difficulty to perform gross motor skills like extending and lifting of the left arms Unsteady gait Slowed movement Right arm (EDNA PAKIFILL UP NA LANG ACC. DUN SA NA ASSESS!!!! THANKS^^)

Diagnosis

Impaired physical mobility r/t neuromuscular damage involvement (Left arm numbness) as evidenced by motor control

Scientific Explanation

CVA can be caused by an occlusion in the blood flow. This can lead to O2 and the cause failure to nourish the tissues at the capillary level and that can cause neuromuscular damage w/c can cause impaired physical mobility

Planning

After 8 hrs of nursing intervention,client will maintain muscle integrity and tone.

Interventions and Rationales

1. Determine degree of immobility to establish comparative baseline 2. Do passive range of motion exercises to promote blood flow and tissue perfusion and prevent muscle atrophy. 3. Reposition every 15 minutes on affected side and 2 hours on unaffected side, to prevent development of pneumonia 4. Assist in positioning, transferring and lifting procedures using proper techniques to prevent any injury to the patient.

Evaluation

After 8 hours of nursing interventions, patient's muscle tone and muscle integrity were maintained.

2. Risk for Impaired Skin Integrity

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Assessment:

O> weakness of left side of the body due to stroke

Diagnosis:

Risk for Impaired Skin Integrity R/T Impaired Bed Mobility

Scientific Explanation

>Bed Immobility resulting from cardiovascular accident----> Decreased perfusion to the skin in back and parts carrying patient's weight, Irritation to the skin, Skin is thinner due to the escape of fluid to the extracellular space----> Pressure Ulcers, Skin Rashes (Impaired Skin Integrity)

Planning

After 3 hours of nursing interventions, >Patient will have no/reduced risk of developing impaired skin integrity >Significant others will be able to identify risk factors for impaired skin integrity and report these to the nurse on duty >Significant others will be able to demonstrate techniques to prevent skin breakdown

Interventions and Rationales

>Assess Patient's skin condition routinely, noting for moisture, color and elasticity. These factors may contribute to the development of pressure ulcers. >Handle client gently, to prevent trauma. >Inspect skin surfaces and pressure points routinely. These pressure points are the common sites of pressure ulcers because the soft tissues are put againts bony surfaces. >Observe for reddened or blanched areas of the skin, rashes and institute treatment immediately, to reduce progression to to skin breakdown.

>Maintain skin hygiene by using warm water and mild soap, drying gently and thoroughly in a patting motion and applying lotion as indicated. Reduces skin irritaion and dryness which may lead to skin breakdown. >Massage bony prominences and reposition patient every two hours, using proper positioning, turning, lifting and transferring techniques, to promote circulation and prevent friction or shear injury. >Provide for bedside care, change soiled linens, smoothing creases on bed covers. Creases on bed covers can slow perfusion in the skin. Linens that may be soiled with urine, feces or discharges from the Patient may irritate the skin. >Teach and instruct significant others about Skin breakdown and Pressure ulcers, its prevention, the procedures done and its purposes, for continuity and participation of Significant other for the patient's care.

Evaluation

After 3 hours of nuring intervention rendered: >Patient's risk for impaired skin integrity was reduced. >Significant others were able to identify the risk factors that may contribute to skin breakdown and were reported accordingly. >Significant others were able to demonstrate techniques in the prevention of skin breakdown as evidenced by verbalization of when they were asked about the procedures done.

3. Impaired cerebral tissue perfusion

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Assessment

O>w/ contralateral hemiparesis, sensory loss, muscle weakness, slurred speech, with GCS=15 (pls Edit)****

Nursing Diagnosis

Impaired cerebral tissue perfusion r/t vascular occlusion secondary to disease condition

Scientific Explanation

In cerebral tissue perfusion, there is a decrease in oxygen supply which results in the failure to nourish the tissues at the capillary level. Blood vessels which function is to supply blood to the different parts of the brain are impaired. Thus, the O2 supply going to the brain is also impaired. Proper perfusion is needed in order to give adequate nourishment to the different parts of the brain in order for it to function well.

Planning

After 5hrs. of Nursing intervention, the pt. will demonstrate increased perfusion as individually appropriate

Interventions and Rationales

>Monitor Vital signs to identify any other deviations from normal.

>Position patient in semifowlers position w/ head midline to aid with proper perfusion or flow of blood (circulation or venous drainage).

>Administer medications as ordered such as antihypertensive or diuretics. to probably decrease cardiac workload and in maximizing tissue perfusion >Encourage quiet environment to prevent occurrence of seizures.

Evaluation

After 5hrs. of Nursing intervention, the pt. shall be able to demonstrate increased perfusion as individually appropriate

4. Risk for Aspiration

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Assessment

O> Depressed gag reflex, reduced level ofconsciousness

Diagnosis

Risk for Aspiration

Scientific Explanation

When there is a blockage of vertebrobasilar artery there will be Cranial nerves affectations. CN V, VII, IX, XII blockage may result to dysphagia or difficulty of swallowing which thereby having high risk for aspiration.

Planning

After 5hrs. of Nursing intervention, the pt. demonstrate techniques to prevent aspiration.

Interventions and Rationales

>Monitored Vital signs to identify any other deviations from normal.

>Note level of consciousness of surroundings, and cognitive impairment to assess if there is gag reflex or difficulty of swallowing. >Suction as needed to clear secretions >Auscultate lung sounds to determine presence of secretions >Give semisolid foods; avoid pureed that may increase risk of aspiration. to preven aspiration and to aide swallowing effort.

Evaluation

The patient shall have demonstrated techniques to prevent aspiration.

5. Risk for Infection

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Assessment

O> with intact Endotracheal tube attached to mechanical ventilator, with intact urinary catheter

Nursing Diagnosis

Risk for Infection related to Stasis of body fluids(edema) and Invasive procedures( ET tube, Urinary Catheter)

Scientific Explanation

Invasive procedures is a potent portal of entry for pathogens which may cause infection.

Planning

After 1 hour of nursing interventions >Patient will have decreased risk for infection. >Patient will remain afebrile >Significant others will be able to demonstrate techniques and interventions to prevent or reduce risks for infection.

Interventions and Rationales

>Observe for localized signs of infections at insertion sites of Endotracheal tube and urinary catheter,for immediate intervention and control of infection. >Monitor changes in patient's temperature and intervene as needed. Fever may be the earliest sign of infection. >Provide regular urinary catheter/perineal care to reduce risk of ascending urinary tract infection. >Ensure sterility of solution in Mechanical ventilator's humidifier to prevent direct infection of the lungs. >Wash hands before and after during procedures to the client to minimize the occurrence of Healthworker-acquired infections. >Teach and instruct significant others about proper hand washing or hand hygiene practices, its purpose and how it can reduce risk of infection to reduce contracting infection to the patient.

Evaluation

After 1 hour of nursing interventions >Patient's risk of contracting infection was decreased. >Patient remained afrebrile and free of signs and symptoms of infection. >Significant others were able to demonstrate techniques and interventions to prevent or reduce risks for infection.