Question

Write a Nursing Care plan on

- Pt. with CVA with Right side Hemiplegia.

Extra Information - Pt. has sepsis, hypertension, seizure disorder , Coronary heart disease , MI, rales present in lungs.

Please provide -

- one Nursing Diagnosis.

- Two outcomes / goals .

- 5 interventions.

Answer 1

CVA is Cerebro Vascular Accident.The causes could be Thrombosis, Embolism, Haemorrhage, Ischemia occuring in the cerebral artery Clinical manifestations: are Haemiparesis(weakness),Heamiplegia(paralysis of one side of the body),Aphasia(inability to communicate), dysarthria( imperfect articulation that causes difficulty in speaking),Dysphagia(difficulty in swallowing),Visual changes,Agnosia(inability to recognise familiar object)Horners syndrome(paralysis of sympathetic nerves of the eyes), behaviuoral changes and incontinence of urine.

NURSING CARE PLAN

NURSING DIAGNOSIS	GOAL	NURSING INTERVENTION	OUTCOME
1.Impaired physical mobility related to loss of muscle tone secondary to flaccid paralysis or spasticity.	To enable the client to acheive maximum physical mobility and prevent further complications.	Assess the general condition of the patient,the level of activity, degree of muscle strength.	The client will acheive maximal physical mobility within the limitations imposed by the stroke, as evidenced by more normal movement of the affected extremity.
		Encourage bed exercises for the patient example asking the patient to use the unaffected arm to move the affected arm.	To improve the muscle strength and to enable effective use of adaptive devices.
		Helping the client to sit up with assistance and precaution to prevent orthostatic hypotension.
		Teach the client how to use the wheel chair from bed to chair, commode etc once the patient is competent to learn and balance.
		Reassure the client and provide psychological support so as to improve their confidence level.