Monday, April 16, 2012

Impaired Physical Mobility - Ineffective Cerebral Tissue Perfusion related to CVA / Stroke

Nursing Diagnosis and Nursing Interventions for CVA / Stroke

1. Nursing Diagnosis: Impaired Physical Mobility related to the function of neurological damage.

Nursing Interventions:
  • Assess the functional capabilities and severity of abnormalities.
  • Maintain body alignment (using a board bed, air mattress or a standard board as indicated.
  • Turn and change position every 2 hours.
  • Elevate the extremity pain with pillows.
  • Perform range of motion exercises for all active or passive limb every 2 hours to 4 hours.
  • Encourage hands, fingers and leg exercises.
  • Give the patient as indicated ancillary equipment.
  • Encourage the patient to perform activities of daily needs.
  • Start to order a progressive ambulation aids to sit in a balanced position from the procedures to move from bed to a chair to reach equilibrium.
  • Consult with the physician and the treatment (Tucker, 1998).

2. Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow, occlusive disorders, hemorrhage, cerebral vasospasm, cerebral edema.

Nursing Interventions:
  • Monitor or record the neurological status as often as possible and compare it to standard or normal state.
  • Monitor vital signs.
  • Record the data changes such as the blindness of vision, or visual field disturbances in perception.
  • Assess the higher functions, such as speech function.
  • Put your head slightly elevated position and the anatomical position (neutral).
  • Maintain a state of bed rest, creating a peaceful environment, limit the activities of visitors or patients as indicated.
  • Help prevent the occurrence of straining during defecation and breathing force (continuous cough).
  • Collaboration in pembarian oxygen and drugs as indicated (Doenges, 2000).

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