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:

Anxiety

• 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