Question

A patient have a history of CVA (right cerebellar damage), has a left sided weakness, hypertension, hyperlidipemia, and recent electrolytes imbalances (low). Patient has labs of increase PTT and INR and receives blood thinner (Lovenox). With a Neuro focused assesment, what is a good-
1. Short term goal:
2. Long term goal:
3. At least 6 nursing interventions:
4. influecing Pschosocial/ Cultural Aspect: (Two Physical and Two Pschosocial):
5 Patient/Family Teaching:

Answer 1

Patient is having cerebrovascular accident, the nursing care plan given are as follow:

1. Short term goal:

- risk for bleeding related to hypoprothrombinemia as evidenced by increased in the prothrombin time and INR.

- inadequate pumping of blood by the heart to meet the body's metabolic need.

- impaired physical mobility related to weakness as evidenced by inability to complete daily activity tasks.

- fluid and electrolyte imbalance less than body requirement.

- fatigue related to loss of fluid and electrolyte.

- imbalanced nutrition more than requirement related to increase in appetite.

2. Long term goal:

- knowledge deficit related to long term use of anti coagulant.

- ineffective tissue perfusion related to interruption of the blood flow to the brain.

- impaired verbal communication related to loss of facial muscle tone.

- altered sensory perception related to poor concentration and altered thought process.

3. Nursing interventions:

a. Altered sensory perception related to poor concentration and altered thought process.

- assess the pathological condition of the patient.

- assess or observe the behavioural changes in the patient like crying, inappropriate affect, agitation etc.

- build and maintain proper communication with the patient inorder to win his confidence.

- maintain a peaceful and quiet environment for the patient.

- communication should be in a calm and contained manner and should be short.

- assess for the patient's sensory awareness ranging to dull from sharp.

4. Patient and family teaching:

- inform the family members about the patients bleeding condition and the risk of it.

- inform the patient as well as the family members about the risk of getting tiredness and fatigue even when doing a small daily activities.

- tell the patient to take proper bed rest.

- ask the patient to stay away from falls and injuries.