Aplikasi Merah Putih

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Nursing Diagnosis Nursing care plan for Stroke Cerebrovascular Accident

Diagnostic tests for Stroke Cerebrovascular Accident
  • Computed tomography scan.
  • Magnetic resonance imaging.
  • Electrocardiogram.
  • Carotid duplex may detect carotid artery stenosis.
  • Angiography.
  • EEG helps to localize the damaged area.
Nursing Diagnosis Nursing care plan for Stroke Cerebrovascular Accident
Diagnosis of stroke is based on observation of clinical features, a history of risk factors, and the results of diagnostic tests, Nursing Diagnosis for Stroke Cerebrovascular Accident:

  • Self-Care Deficit: bathing/hygiene, dressing/grooming, feeding, toileting
  • Disturbed sensory perception: Tactile
  • Impaired gas exchange
  • Impaired physical mobility
  • Impaired verbal communication
  • Ineffective airway clearance
  • Ineffective tissue perfusion: Cerebral
  • Powerlessness
  • Risk for aspiration
  • Risk for disuse syndrome
  • Risk for impaired skin integrity
  • Risk for infection
  • Risk for injury
  • Situational low self-esteem
  • Toileting self-care deficit
  • Total urinary incontinence
Nursing Outcomes Nursing Care Plan For Stroke Cerebrovascular Accident
Nursing Outcomes Nursing Care Plan For Stroke Cerebrovascular Accident patient will:

Identify strategies to reduce anxiety.
  • Perform bathing and hygiene needs to the fullest extent possible.
  • Report signs and symptoms of impaired sensation.
  • Perform dressing and grooming needs to the fullest extent possible.
  • Maintain adequate ventilation and oxygenation.
  • Achieve the maximum mobility possible within the confines of the condition.
  • Effectively communicate needs verbally or through an alternative means of communication.
  • Maintain a patent airway.
  • Exhibit signs of adequate cerebral perfusion.
  • Express feelings of control over health and well-being.
  • Free from signs of aspiration.
  • Maintain joint mobility and range of motion (ROM).
  • Maintain intact skin with no signs of breakdown.
  • Remain free from signs or symptoms of infection.
  • Free from injury.
  • Verbalize feelings regarding self-esteem.
  • Perform toileting needs to the fullest extent possible.
  • Identify strategies to reduce incontinent episodes.
Nursing Interventions Nursing care plan for Stroke Cerebrovascular Accident

Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
  • Provision of a modified environment for the patient who is experiencing a confusional state
  • Calming Technique: Reducing anxiety in patient experiencing acute distress
  • Self-Care Assistance: Assisting another to perform activities of daily living
  • Bathing: Cleaning of the body for the purpose of relaxation, cleanliness, and healing
  • Hair/Nail Care: Promotion of neat, clean, attractive hair/nails and prevention of skin lesions related to improper care of nails
  • Feeding: Providing nutritional intake for patient who is unable to feed self
  • Bowel/Urinary Elimination Management: Establishment and maintenance of a regular pattern of bowel elimination/Maintenance of an optimum urinary elimination pattern
  • Communication Enhancement: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision
  • Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
  • Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit
  • Peripheral Sensation Management: Prevention or minimization of injury or discomfort in the patient with altered sensation
  • Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
  • Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
  • Airway Management: Facilitation of patency of air passages

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