Diagnostic tests for Stroke Cerebrovascular Accident
- Computed tomography scan.
- Magnetic resonance imaging.
- Carotid duplex may detect carotid artery stenosis.
- 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
- 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