NCP Cerebrovascular Accident PDF

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Summary

A nursing care plan for cerebrovascular accidents such as stroke...

Description

Assessment

Nursing Diagnosis

Planning

Nursing interventions /rationale

evaluation

Problem: blocked right internal carotid artery

Ineffective cerebral tissue perfusion related to occluded R. internal carotid artery secondary to thrombus formation

NOC: Neurological Status

NIC: Cerebral perfusion promotion

Goal met, the patients cerebral tissue perfusion increased and was evidenced by an assessment of ‘oriented’ from the GCS after 6 hrs of independent and dependent nursing therapy

Subjective: -sudden onset numbness and tingling in R. limb - pain in L. arm (8/10 on pain scale) -Slight headache Objective: - Confused -Slurred speech -Left hemiparesis -left visual/spatial neglect -BP 150/95 mmHg

CT scan results: - thrombus present in branch of right internal carotid artery @ 50% occlusion due to atherosclerosis - area of infarction in R. anterior hemisphere

Goal: After 6 hrs of nursing intervention, pt will display decreased signs Rationale: of ineffective cerebral The client is seen with tissue perfusion as changes in level of consciousness. She has a evidenced by improved level of consciousness pain in the arm and headache. She has slurred from confused to speech and these ‘FAST’ oriented signs agree with the CT After 6 hrs of nursing scan which confirms the presence of a thrombus in intervention, pt will display decreased signs the carotid (Brunner & of ineffective cerebral Suddarth, 2018) tissue perfusion as evidenced by a reduced level of pain from 8/10 to 5/10

-Closely assess and monitor neurologic status frequently and compare with baseline aqquired upon entry to ER Rationale: In order to predict life threatening complications and to intervene at the earliest stage of complication. (Brunner & Suddarth, 2018) -position with head slightly elevated in a neutral position. Rationale: this reduces the arterial pressure by promoting venous flow due to gravity thus reducing intracranial pressure and improving cerebral perfusion (Veera,2019) -Maintain bedrest and provide a quiet, relaxing environment. Be sure to restrict visitors and limit duration of procedures Rationale: activity or continuous stimulation can increase the intracranial pressure of an individual and may also agitate the patient. (Brunner & Suddarth,2018) -document changes in vison, assess the patients L side. Rationale: ischemic stroke can cause irreversible changes such as paraplegia and other sensory disabilities. These need to be assessed to grade the extent of damage to the brain (Ackley, Ladwig & Makic, 2017) - Administer rt-PA, aspirin antiplatelet therapy as per doctor’s order with the correct respective doses Rationale: thrombolytic therapy can be started

Goal met, the patients cerebral tissue perfusion increased and was evidenced by a reduction in the patients pain from 8/10 to 5/10 after 6 hrs of independent and dependent nursing therapy

because she fits the criteria and it is within the golden hours, this therapy dissolves the clot and thus alleviates symptoms and promotes recovery from complications such as hemiplegia. (Ackley, Ladwig & Makic, 2017)

Problem 1 (ER SCENE)

Assessment

Nursing Diagnosis

Planning

Nursing interventions w rationale

Problem: Visual/ spatial neglect on the left

Disturbed sensory perception r/t infarction on R. anterior hemisphere secondary to occlusion of R. carotid

NOC: Cognitive orientation

NIC: Reality orientation

Subjective: -sudden onset numbness and tingling in R. limb - pain in L. arm (8/10 on pain scale) -Slight headache Objective: - Confused and disoriented -unable to identify the family members that brought her to the ER -Slurred speech -poor concentration -Left hemiparesis -left visual/spatial neglect -inability to tell position of body parts -BP 150/95 mmHg -motor incoordination -altered communication pattern

Rationale: Different regions of the brain have different functions, the right side specifically the anterior side is responsible for the perception, memory, and interaction ability of the individual. When infarction occurs, cells lose their ability to function and eventually experience cell death. (Brunner & Suddarth, 2018)

Goal: After 3days of nursing intervention, the client will show signs of orientation as evidenced by being able to identify the current place they are in and identify the day and season. After 3 days of nursing intervention, the patient will gain spatial awareness over the left side of their body and it will be evidenced by a sensory and spatial knowledge test of the room requiring the patient to get 5 items correct out of 7 tries.

-Evaluate for visual deficits and note the loss of visual field. Rationale: this complication can worsen and eventually change and affect the patient’s ability to perceive from the environment and relearn the motor skills from the rehabilitation therapy (Ackley, Ladwig & Makic, 2017) -Eliminate extraneous noise and stimuli as necessary Rationale: this will reduce the stress and anxiety related to confusion and sensory overload (Ackley, Ladwig & Makic, 2017) -Speak in a calm and comforting voice using short sentences while maintaining proper eye contact Rationale: this will allow the patient to pay attention to the nurse therefore allowing the nurse to orient the client about the environment and in general be able to communicate with her (Brunner & Suddarth, 2018).

evaluation

Goal met, after 3days of both independent and dependent nursing intervention, the client showed signs of orientation as evidenced by being able to identify the place, day and season Goal met, after 3 days of independent and dependent nursing intervention, the patient was able to gain spatial awareness over the left side of her body and she was able to identify 5 items correctly out of 5 tries

CT scan results: - thrombus present in branch of right internal carotid artery @ 50% occlusion due to atherosclerosis - area of infarction in R. anterior hemisphere

-Approach patient from the visually intact side and use artificial lighting and place items of the pt on the side of intact visual fields. Rationale: this will help the patient recognize people and be more oriented to the surroundings. This helps the patient to get used to the sensory stimuli and eventually cope (Ackley, Ladwig & Makic, 2017) -Practice proper aseptic technique when changing dressing or cleaning incision Rationale: this prevents infections (Brunner & Suddarth, 2018). - Administer rt-PA, aspirin antiplatelet therapy as per doctor’s order with the correct respective doses Rationale: thrombolytic therapy can be started because she fits the criteria and it is within the golden hours, this therapy dissolves the clot and thus alleviates symptoms and promotes recovery from complications such as hemiplegia. (Ackley, Ladwig & Makic, 2017)

Problem 2 (ER scene)...