NCP- CVA- Self- Care- Deficit by nurseslabsdocs

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									Medical Diagnosis: Cerebrovascular Accident
Problem: Self Care Deficit RT Musculoskeletal Impairment

    Assessment             Nursing Diagnosis            Scientific                 Planning                   Interventions              Rationale                Evaluation
Subjective: (none)        Self Care Deficit R/t   Motor deficit are the     Short Term:                  1. establish rapport       1. to promote           Short Term:
                          musculoskeletal         most obvious effect of    After 4 hrs of NI, pt will   2. monitor vital signs        cooperation          Pt shall have identified
Objective:                impairment secondary    stroke. Symptoms are      be able to identify          3. Assess for type         2. to have a            personal resources that
   with soiled clothes   to CVA                  caused by destruction     personal resources that         and severity of            baseline data        can provide assistance
   with unsatisfying                             of motor neurons in       can provide assistance                                                          and be able to
                                                                                                            immobility              3. Provides data
    appearance                                    the pyramidal             and be able to                                                                  verbalized knowledge
                                                  pathways (nerve fibers
                                                                                                            impairment,                regarding
   with minimal                                                            verbalize knowledge of                                                          of health care
                                                  in the brain and          health care practices.
                                                                                                            muscle flaccidity,         mobility and         practices.
    sweating                                                                                                spasticity and             ability to perform
                                                  passing through the
   uncombed hair                                                                                           coordination,              activities with in
                                                  spinal cord to the        Long Term:
                                                  motor tract.) One of      After 3 days of NI, pt.         ability to walk, sit,      limitations          Long Term:
                                                  those symptoms could      will demonstrate                move in bed                without injury or    Pt shall have
                                                  be inability to perform   techniques/ lifestyle           perform                    frustrations.        demonstrated
                                                  ADLS.                     changes to meet self-                                                           techniques/ lifestyle
                                                                            care needs                                                                      changes to meet self-
                                                                                                                                                            care needs
                                                                                                         4. passive ROM to all      4. promotes
                                                                                                            limbs and progress         circulation,
                                                                                                            to assistive and           muscle tone,
                                                                                                            then active ROM            joint flexibility,
                                                                                                            in all joints four         prevents
                                                                                                            times a day                contractures and

                                                                                                         5. use assistive           5. Provides safe
                                                                                                            devices as                 support for
                                                                                                            appropriate for            immobility and
                                                                                                            ambulation,                other self care
                                                                                                            clothing with              activities to
                                                                                                            zipper closures,           promote
                                                                                                            suction cups on            independence.
                                                                                                            personal hygiene

articles for
brushing teeth,
combing hair,
clothing that is
easily managed to
dress and undress


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