Nursing Care Plans | 12/22/2011, 1:08 am

Hemorrhagic Stroke Nursing Care Plans

Cerebrovascular accident (CVA) 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 result 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.

Impaired Physical Activity - Hemorrhagic Stroke Nursing Care Plans

NDx: Impaired physical mobility r/t neuromuscular impairment secondary to CVA

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

Objectives

Nursing Interventions

Rationale

Expected Outcome

S> (none)

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

Short Term:

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

Long 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.

Here are also 14 Nursing Care Plans for Stroke