Nursing Care for Patient
Cerebrovascular Accident (Stroke)
Chapter I
Theorytical Nursing Diagnose
1.1 Definition of Disease
Stroke is injuring brain of related to obstruksi of blood stream brain ( Elisabeth J. Corwin, 1991 ; 181).
Injuring serebrovaskuler or stroke represent the serebrovaskuler showing the existence of some brain disparity either through structural and also functional which is because of circumstance patofisiologis from vein serebral or from entire/all venous system of brain ( Doenges, 2000 ; 290).
1.2 Nursing Diagnose
1.2.1 Mobility impairment Related to Pain or discomfort
a Definition
Limitation of physical movement.
b Assesment
• History of recent surgery, injury, or disorder causing pain or discomfort.
• Medication history.
• Musculoskeletal status, including coordination, gait, muscle size and strength, muscle tone, range of motion, and functional mobility as follows :
0 = completely independent
1 = requires use of equipment or device
2 = requires help, supervision, or teaching from another person
3 = requires help from another person and equipment or device
4 = dependent; doesn’t participate in activity
• Pain, including environmental and cultural influences, intensity, location, quality, temporal factors
• Psychosocial status, including coping mechanisms, family or significant other, life-style, personality, stressors (disease process, finances, job, marital discord)
c Defining Characteristics
• Clinical evidence or verbal complaint of pain on movement
• Decreased muscle streght, control, mass, or endurance
• Impaired coordination
• Imposed restriction of movement, including mechanical; medical protocol
• Inability to move purposefully within the physical environment, including bed mobility, transfer, and ambulation
• Limited range of motion
• Reluctance to attempt movement
d Expected Outcomes
• Patient displays increased mobility.
• Patient shows no evidence of such complications as contractures, venous stasis, thrombus formation, or skin breakdown.
• Patient or significant other demonstrates mobility regimen.
• Patient states feelings about limitations.
e Interventions and Rationales
• Observe patient’s functional ability daily; document and report any changes using functional mobility scale (see assessment). Change may indicate progressive decline or improvement in underlying disorder.
• Perform prescribed treatment regimen for underlying condition producing pain or discomfort. Monitor progress and report favorable and adverse response to treatment to assess effectiveness of treatment.
• Discuss use of distraction and other nonpharmacologic pain-relief methods with patient. Instruct patient and family or significant other on the preferred method and monitor effectiveness. Encourage patient to choose an alternative if ineffective. Document response. In addition to providing pain relief, nonpharmacologic techniques may help patient achieve sense of control. Documentation help ensure continuity of care.
• Instruct patient and significant other in range-of-motion exercises, transfer, skin inspection, and mobility regimen. Have patient and signification other return mobility demonstration under supervision. Education will enable patient and significant other to prevent complications of immobility.
• Encourage adherence to other aspects of health care management to control or minimize effects on mobility. This promotes health and well being by alleviating pain and preventing complications.
• Refer to psychiatric liaison nurse, social service agency, support group, or other resources as appropriate to provide patient with alternative approaches to care.
f Evaluation
• Patient demonstrate increased mobility.
• Patient shows no evidence of contractures, venous stasis, thrombus formation, skin breakdown, hypostatic pneumonia, or other complications.
• Patient attains highest mobility level possible as determined by health care team (specify).
• Patient or signification other carries out mobility regimen.
g Documentation
• Patient’s expression of feelings and concerns about immobility, impact on life-style, and willingness to participate in care
• Observations of patient’s impaired mobility, pain, and response to treatment.
• Instructions to patient and significant other, their understanding of instructions, and demonstrated skill in carrying out the prescribed mobility and pain-relief program
• Patient’s response to nursing interventions
• Evaluation for each expected outcome.
1.2.2 Nutrition Alteration : Less than Body Requirements Related to Inability to Digest or Absorb Nutrien because of Biological Factors
a Definition
Change in normal eating pattern that results in changed body weight
b Assesment
• GI assessment, including antibiotic therapy, auscultation of bowel sounds, change in bowel habits, stool characteristic, history of GI disorder or surgery, inspection of abdomen.
• Nutritional status, including change in type of food tolerated
• Psychological status
• Activity level
• Coping behaviors
• Body image
c Defining Characteristic
• Abdominal pain with or without pathologic condition
• Poor muscle tone
• Poor skin turgor
• Pressure sores
• Pale conjunctiva and mucous membranes
d Expected Outcomes
• Patient shows no further evidence of weight loss
• Patient and family or significant other communicate understanding of preoperative instructions
• Patient and family or significant other communicate understanding of special dietary needs
• Patient and family or significant other demonstrate ability to plan diet after dischaarge
e Interventions and Rasionales
• Obtain and record patient weight at the same time every day to obtain the most accurate readings
• Monitor fluid intake and output because body weight may increase as a result of fluid retention
• Maintain parenteral fluid as ordered to provide patient with needed fluids and electrolytes
• Monitor electrolyte and report abnormal values. Poor nutritional status may cause electrolyte imbalances
• Involve family and significant other in meal planning to enccurage them to help patient comply with diet regimen after discharge
f Evaluation
• Patient remain at or above specific weight
• Patient weiught increase by specific amount weekly
• Patient consumes specified number of calories daily
• Patient and family coomunicate understanding of special dietary needs
• Patient and family plan appropriate diet for patient to follow after discharge
g Documentation
• Daiy weight
• Mouth care
• Intake and output
• Patient ability to eat
