Question

Nursing experts only please. Care plan /homework

Maria J., an 86-year-old, has a history of cerebrovascular accident (CVA), 3 years ago. She has right sided weakness and expressive aphasia with minimal dysphagia. Maria J. also has a medical history of atrial fibrillation and hypertension. She lives with her daughter since the stroke. Since admission to an acute care facility 4 days ago, Maria J. has gained some strength, has become more oriented to person and place, and is anxious to start her rehabilitation program.
Below are instructions
The following pages must be completed

a) Demographics

b) Lab and Diagnostics page

c) The first Nursing process page

please follow NANDA-

Answer 1

A. Name : Ms. Maria J

Age : 86years

Gender: female

Date of admission: 16.2.2019( four days ago)

Medical diagnosis: cerebro vascular accident, fibrillation and hypertension

B. Lab and diagnostics

* CSF analysis

* CT scan

* MRI scan

* electro encephalogram

* electro cardiography

* X ray

* PET

C. The nursing process:

1. Ineffective cerebral tissue perfusion related to interruption of blood flow as evidenced by poor speech

Outcome:

* maintain normal sensory perception(speech)  

* display no further deterioration or recurrence of the deficits

Interventions with rationale

* closely assess to the neurological status and compare with baseline in order to assess level of consciousness and potential for increased ICP

* provide the opportunity for the training of speech through a specch therapist in order to improve the speaking skills

*

Monitor and assess the vitals to be more clear and to have the stable stay

* provide the position which is head slightly elevated and in neutral position in order to know the extent of the deterioration.

* maintain bed rest and calm environment wereby it reduces the individuals ICP to be increased

* encourage patient not to strain while passing stool as this may led to increased ICP and the integral arterial bleeding

* administer supplemental oxygen to reduce hypoxemia

Evaluation

* patient is oriented to person and place to some extent

2. Anxiety related to rehabilitation programmes as evidence by patients verbalization.

Outcome

* patient demonstrates his coping strategies to come out of fear

* patient vaerbalises reduced anxiety

Interventions with rationale

* assess the level of anxiety to provide a proper education nd awareness

* encourage the patient to ask doubts

* clear all the doubts of patients

* teach the coping strategies and demonstrate few like yoga, meditation

* explain the importance of rehabilitation and how it works

* introduce the patients who underwent the same programme and show the effectiveness in order to reduce anxiety

* arrange for a psychiatrist if the patient need him in order to start with anti anxiolytics.