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Monday, March 29, 2010

Nursing Care for Patient-CVA

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

Infection, hight risk for related to external factors

1.2.3 Infection, hight risk for related to external factors

1.2.3.1 Definition
Presence of internal or external hazards that threten physical well-being.

1.2.3.2 Assessment
- Health history, including accidents, allergies, falls, hyperthermia, hypothermia, poisoning, seizures, trauma, exposure to pollutants.
- Sensory or perceptual changes (auditory, tactile, visual).
- Circumstances of present situation that could lead to infection.
- Neurologic status, including level of consciousnes, mental status, orientation.
- Laboratory studies, including cloting factors, hemoglobin and hematocrit, platelet count, serum albumin, white blood cell count, and cultures of blood, body fluid, sputum, urine, wounds.

1.2.3.3 Risk factors
- Admission to hospital
- Age (over 65)
- Chemotherapy
- Hemodialysis
- Hemodialysis
- Hospitalized longer than 1 month
- Immobility
- Indwelling urinary catheter
- Intravenous catheter
- Invasive monitoring procedures
- Obesity
- Prophylactic antibiotic therapy
- Respiratory treatments (endotracheal or tracheostomy tube, humidifier or nebulizer, ventilator)
- Steroid therapy
- Surgical procedure

1.2.3.4 Expecected outcomes
- Temperature stays within normal range.
- White blood cell count and differential stay within normal range.
- No pathogens appear in cultures.
- Patient maintains good personal and oral hygiene.
- Respisatory secretions are clear and odorless.
- Urine remains clear yellow, odorless, with no sediment.
- Patient shows no evidence of diarhea.
- Wounds and incisions appear clean, pink, and free of purulent drainage.
- I.V. sites show no signs of inflammation.
- Patient shows no evidence of skin breakdown.
- Patient takes___ml of fluid and___g of protein daily.
- Patien states infection risk factors.
- Patient identifies signs and symptoms of infection.
- Patient remains free of all signs and symptoms of infection.
1.2.3.5 Interventions and retionales
INTERVENTIONS
1. Minize patient' risk of infection by:
- Washing hands before and after providing care.
- Wearing gloves to maintain asepsis when providing direct care.
2. Monitor temperature at least every 4 hours and record on graph peper. Report elevations immediately.
3. Monitor WBC count, as ordered. Report elevations or depressions.
4. Culture urine, respiratory secretions, Wound drainage, or blood according to hospital policy and doctor's order.
5. Help patient wash hands before and after meals and after using the bathroom, bedpan, or urinal.
6. Assist patient when necessary to ensure that the perianal area is clean after elimination.
7. Intruct patient to report incidents of loose stools or diarrhea. Inform the doctor immediately.
8. Offer oral hygiene to the patient every 4 hours to prevent colonization of bacteria and reduce the risk of de scending infection.
9. Use strict aseptic technique when suctioning the lower airway, inserting indwelling urinary catheters, inserting I.V. catheters and providing wound care.
10. Change I.V. tubing and give site care every 24 to 48 hours or as hospital policy dictates.
11. Rotate I.V. sites every 48 to 72 hours or as hospital policy dictates.
12. Have patient cough and deepbreathe every 4 hours after sugery.
13. Provide tissues and disposal bag for expectorated sputum.
14. Help patient turn every 2 hours. Provide skin care, particularly over bony prom4nences.
15. Use sterile water for humidifcation or nebulization oxygen.
16. Encourage fluid intake of 3,000 to 4,000 ml daily, unless contraindicated.
17. Arrange for reverse isolation if patient has comprimised immune system. Monitor flow and number of visitors.
18. Educate the patient regarding:
-good hand-washing technique
-factors that increase infection risk
-infection signs and symptoms.

RATIONALES
1.
- Handwashing is the single best way to avoid spreading pathogens.
- Gloves offer protection when handling wound dressings or carriying out various treatments.
2. Sustained temperature elevation after surgery may signal onset of pulmonary complications, wound infection or dehiscence, urinary tract infection, or thrombophlebitis.
3. Elevated total WBC count indicates infection. Markedly decreased WBC count may indicate decreased production resulting from extreme debilitation or severe lack of vitamins and amino acids. any damage to bone marrow may suppress WBC formation.
4. This identifies pathogens and guides antibiotic therapy.
5. Hand washing prevents spread of pathogens to other objects and food.
6. Cleaning perineal area by wiping from area of least contamination (urinary meatus) to area of most contamination (anus) helps prevent genitourinary infections.
7. Disease and malnutrition may reduce moisture in mocous membranes of mounth and lips.
8. To avoid spreading pathogens.
9. To help keep pathogens from entering the body.
10. To reduce chances of infection at individual sites.
11. To help remove secretions and prevent pulmonary complications.
12. Convenient disposal encourages expectoration; sanitary disposal reduces spread of infection.
13. To help prevent venous stasis and skin breakdown.
14. This prevents drying and irritation of respiratory mucosa, impared ciliary action, and thickening of secretions within respiratory tract.
15. To help thin mucous secretions.
16. This helps stabilize weight, imroves muscle tone and mass, and aids wound healing.
17. These measures protect patient from pathogens in the environment.
18. These measures allow patient to participate in care and help patient modify life-style to maintain optimum health level.

1.2.3.6 Evaluations for expected outcomes
- Patient's temperature remains within normal range.
- Patient's WBC count and differential remain within normal range.
- Cultures do not exhibit pathogen growth.
- Patient demonstrates appropiate personal and oral hygiene.
- Patient's respiratory secretions remain clear and odorless.
- Patient's urine remains clear, yellow, odorless, and free of sediment.
- Patient's bowel patterns remain normal.
- Patient's incisions or wounds remain clear, pink, and free of purulent drainage.
- Patient's I.V. sites do not show signs of inflammation.
- Patient' skin does not exhibit signs of break down.
- Patient's fluid intake remains at specified level.
- Patient consumes specified amount of protein daily.
- Patien risk factors for infection.
- Patien risk factors and symptoms of infection.
- Patient remains free of signs and symptoms of infection.

1.2.3.7 Documentation
- Temperature
- Dates, time, and sites of all cultures
- Dates, time, and sites of all catheter insertions
- Appearance of all invasive catheter sites, tube sites, and wounds
- Interventions performed to reduce infection risk
- Patient's response to nursing interventions
- Evaluations for each expected outcome

Planning-mobility, impairment

mobility, impairment

objective: Patient reports to try a powerfull and joint endurance.

Out came:
- Increase or keeps mobility on level highest one maybe.
- Keeping functional position.
- increase of level sick function.
- Patient can use help equibment to clear a root to increase mobility.

Plan

Independent:
1. Inspect is resulting imobilitas degree by injury or cure and paying attention patient perception to mobility.
2. Giving foot board suitably.
3. Change shoulder joint each 2-4 hours.
4. Advising patient to not lies down by same position in the period of long time.

Collaboration:
1. Consul with physical therapist or specialist rehabilitation.

Rasional:

1. Patient may be drawn the line by view self or perception self about current physical limitation, requiring information or intervention to increase health progress.
2. Behoof in keep ekstermitas functional position to prevents complication,
3. To prevent its happening complication.
4. To prevent exdekubitus's complication.

Collaboration:
1. Behoof in make programing's individual activity training. Patient can require help long range with movement, force and activity that relies body , also using tool.

Planning -Acute Pain

PLANNING
1. Acute pain

propuse : Patient expres that his pain decrease afters get nusing care and that action give satisfy proved one by.
Outcame:
- Patient expres for pain is decrease or get lost.
- Patient points out action or easy going expression.
- Patient can participate deep rest activity gets asleep.
- Downwards blood pressure or normal.

Plan

Independent
1. Keeping imobilitas a part one takes ill with plaster cast.
2. Edvance and happening ekstermitas advocate trauma.
3. Evaluating pain complaint or uncomfortableness, paying attention location and characteristic intensity comprises.
4. observasion is vital sign.
5. Giving accurate information about medical information and nursing care.
6. Create environmentally which cozy for patient.
7. Teaching relaxation tech and distraksi.
8. Put together foot board under right ankle.

Collaborative:
1. Giving Analgesic doctor if optimal ache.
2. Doing cold compress or ices.
3. Plan assembles plaster cast.

Rasionales

1. Removing or decrease pain and prevents bone position fault or tissue strain has oedema.
2. Increasing vena's backwash to decrease oedema and pain.
3. Regarding option or intervention effectiveness observation, ansietas level can regard perception or reaction to pain.
4. Knowing condition developing patient.
5. Reducing patient dread taste.
6. Reducing dread or threat taste that aggravates ache.
7. Reduce or assuages pain.
8. Meminimaly is joint movement to avoid an one gets to aggravate tissue trauma.

Collaborative
1. Given to decrease ache and or muscle spasme.
2. Decrease oedema or hematoma formation , decrease aching sensation.
3. Increasing a cure or ache recovery.