Hemorrhagic Cerebrovascular Accident/Stroke Nursing Care Plans

Nursing Care Plans |

Cerebrovascular accident is the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. It is also known as stroke. CVA can be ischemic or hemorrhagic. Hemorrhagic strokes results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue. The two types of hemorrhagic strokes are intracerebral hemorrhage or subarachnoid hemorrhage. Hemorrhagic strokes have the slowest recovery of all types of stroke.

View 6 more nursing care plans for stroke.

Impaired Physical Activity

CVA is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This is due to the rupture of blood vessels thus causing hemorrhage wherein there is accumulation of blood in the skull. The affected area of the brain with hemorrhage is unable to function leading to inability to move the body

Assessment

Nursing Diagnosis

Objectives

Nursing Interventions

Rationale

Expected Outcome

S> (none)O>> GCS of ____

> Slowed movement

> limited ROM

> Extremity weakness

> limited ability to perform gross or fine motor movement

> Uncoordinated or jerky movements

> Movement induced shortness of breath

Impaired physical mobility r/t neuromuscular impairment secondary to CVA

Short Term:After 3 hours of NI, the SO will verbalize understanding of situation / risk factors & individual treatment regimen & safety measuresLong Term:

After 3 days of NI, the pt will maintain or increase strength and function of affected body part or whole body.

>Establish Rapport>Assess patient condition>Monitor vital signs

>Determine dx that contributes to immobility

>Determine degree of immobility

>Reposition client q2

>Support dependent body parts with pillows

>Provide safety measures including environmental management

>Feed thru NGT

>Encourage SO’s involvement in activities & decision making

>Peroform passive range of motion exercises daily

>Increase functional activities as strength improves

>To gain SO’s trust>To obtain baseline data>For comparison and baseline data

>To assess causative factors

>To assess functional ability

>Prevent development of pressure ulcers

>To maintain position of function and prevent pressure ulcers

>TO reduce risk for falls and further injury

>For optimum energy and nutrition

>Enhances commitment to plan and optimizing outcomes

>To preserve muscle strength and functional ability

>Limits fatigue and ability to perform ADLs.

The SO shall have verbalized understanding of situation / risk factors & individual treatment regimen & safety measuresThe pt shall have maintained or increased strength and function of affected body part or whole body.

View 6 more nursing care plans for stroke.

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