Monday, November 2, 2009

Common Nursing diagnosis found in nursing care plans for stroke is; Impaired verbal communication, Impaired physical Mobility, Anxiety [specify level], Deficient knowledge regarding diagnosis prognosis and treatment options, Risk for disturbed Body Image, Risk for ineffective Sexual Pattern, Self-Care Deficit [specify], Disturbed Sensory Perception (specify), Disturbed Thought Processes, Risk for Injury/Trauma Below is sample of Nursing Outcome, Nursing interventions and evaluation nursing care plans for Stroke

Nursing Intervention Nursing care plans for Stroke
Nursing Diagnosis
Nursing Outcomes
Nursing Intervention
Impaired verbal communication
·      Verbalize or indicate an understanding of the communication difficulty and plans for ways of handling.

·       Establish method of communication in which needs can be expressed.

·      Participate in therapeutic communication (e.g., using silence, acceptance, restating reflecting, Active-listening).

·      Demonstrate congruent verbal and nonverbal communication.

·      Use resources appropriately.

·      Review history for neurological conditions that could affect speech, such as CVA, tumor, multiple sclerosis, hearing loss.

·      Note results of neurological testing such as electroencephalogram (EEG), computed tomography (CT) scan.

·      Note whether aphasia is motor (expressive: loss of images for articulated speech), sensory (receptive: unable to understand words and does not recognize the defect), conduction (slow comprehension, uses words inappropriately but knows the error), and/or global (total loss of ability to comprehend and speak). Evaluate the degree of impairment.

·      Evaluate mental status, note presence of psychotic conditions (e.g., manic-depressive, schizoid/affective behavior). Assess psychological response to communication impairment, willingness to find alternate  of communication.

·      Note presence of ET tube/tracheotomy or other physical blocks to speech (e.g., cleft palate, jaws wired). Determine ability to read/write. Evaluate musculoskeletal states, including manual dexterity (e.g., ability to hold a pen and write).

·      Obtain a translator/written translation or picture chart when writing is not possible.

·      Facilitate hearing and vision examinations/obtaining necessary aids when needed/desired for improving communication. Assist client to learn to use and adjust to aids.

·      Establish relationship with the client, listening carefully and attending to client’s verbal/nonverbal expressions.

·      Keep communication simple, using all modes for accessing information: visual, auditory, and kinesthetic

·      Determine meaning of words used by the client and congruency of communication and nonverbal messages.

·      Validate meaning of nonverbal communication; do not make assumptions, because they may be wrong. Be honest; if you do not understand, seek assistance from others.

·      Individualize techniques using breathing for relaxation of the vocal cords, rote tasks (such as counting), and singing or melodic intonation to assist aphasic clients in relearning speech.

·       Anticipate needs until effective communication is reestablished.

·      Plan for alternative methods of communication (e.g., slate board, letter/picture board, hand/eye signals, typewriter/computer) incorporating information about type of disability present.

·      Provide environmental stimuli as needed to maintain contact with reality; or reduce stimuli to lessen anxiety that may worsen problem.

·       Use confrontation skills, when appropriate, within an established nurse-client relationship to clarify discrepancies between verbal and nonverbal cues.

·      Involve family/SO(s) in plan of care as much as possible. Enhances participation and commitment to plan.
   Response to interventions/teaching and actions performed.

   Attainment / progress toward desired outcome(s).

 • Modifications to plan of care.

Posted bay Lifenurses. Contact me mail lifenurses


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