Nursing Diagnosis and Nursing Intervention

Showing posts with label Stroke. Show all posts
Showing posts with label Stroke. Show all posts

Self-Care Deficit - NCP Stroke

Self-Care Deficit - NCP Stroke
Nursing Diagnosis for Stroke

Stroke is a clinical syndrome that initial sudden onset, rapid progression, a focal neurological deficits and / or global, which lasted 24 hours or more or the direct cause of death, and solely caused by circulatory disorders non-traumatic brain. When the brain's circulatory disorder lasts a while, a few seconds to several hours (mostly 10-20 minutes), but less than 24 hours, referred to as the face of brain ischemia attack (TIA = transient attack ischamia).

Types of stroke

There are two main causes of strokes:
  • ischaemic (accounting for over 80% of all cases) – the blood supply is stopped due to a blood clot
  • haemorrhagic – a weakened blood vessel supplying the brain bursts and causes brain damage

Treatment of stroke

Treatment depends on the type of stroke you have, including which part of the brain was affected and what caused it.

Most often, strokes are treated with medicines. This generally includes drugs to prevent and remove blood clots, reduce blood pressure and reduce cholesterol levels.

In some cases, surgery may be required. This is to clear fatty deposits in your arteries or to repair the damage caused by a haemorrhagic stroke.


Nursing Diagnosis for Stroke : Self-care deficit related to physical weakness

NOC: Self Care Assistance (bathing, dressing, eating, toileting).

Goal: The client can meet the needs of self-care

Outcomes:
Clients are free from odor, can feed themselves, and dress himself.

NIC: Self Care
1. Observation of the client's ability to bathe, dress and eat.
2. Assist the client in a sitting position, make sure the head and shoulders upright for eating and 1 hour after meals.
3. Avoid exhaustion before eating, bathing and dressing.
4. Encourage clients to continue to eat little but often.

Rational:
1. By using direct intervention to determine appropriate interventions for clients.
2. Seated position helps prevent ingestion and aspiration.
3. Improve energy conservation and activity tolerance improved self-care ability.
4. To increase appetite.

NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

Ineffective Cerebral Tissue Perfusion related to interruption of blood flow: occlusive disease, hemorrhage, cerebral vascular spasm, cerebral edema.

Expected outcomes are:
  • Maintained and increased the level of consciousness, cognition and function of sensory / motor.
  • Reveals stabilization of vital signs and no increase in intracranial pressure.
  • The role of the patient reveals no deterioration / recurrence.

Nursing Intervention:

Independent
  • Determine the factors related to individual situations / causes of coma / decreased cerebral perfusion and a potential increase in intracranial pressure.
  • Monitor and record neurological status on a regular basis.
  • Monitor vital signs.
  • Pupil evaluation (size, shape similarity and reaction to light).
  • Help to change the view, misalnay blurred vision, visual field changes / perceptual field of view.
  • Increasing auxiliary functions, including speech if the patient has impaired function.
  • And gradual elevation of the head in neutral position.
  • Maintain bed rest, provide a quiet environment, set visits as indicated.
  • Provide supplemental oxygen as indicated.
  • Give medications as indicated.
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