NotesDefinition
Description
Risk FactorsNonmodifable
Pathophysiology Show Clinical ManifestationsGeneral signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache. Motor Loss
Medical Management
Management of Complications
Nursing AssessmentDuring Acute Phase (1 to 3 days)Weigh patient (used to determine medication dosages), and maintain a neurologic flow sheet to reflect the following nursing assessment parameters:
Assess the following functions:
DiagnosisNursing Diagnoses
Collaborative Problems/Potential Complications
Planning and GoalsThe major goals for the patient (and family) may include improved mobility, avoidance of shoulder pain, achievement of selfcare, relief of sensory and perceptual deprivation, prevention of aspiration, continence of bowel and bladder, improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, and absence of complications. Goals are affected by knowledge of what the patient was like before the stroke. Nursing InterventionsImproving Mobility and Preventing Deformities
Preventing Shoulder Pain
EvaluationExpected Patient Outcomes
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Nursing Care PlanNursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Monitor vital signs:
Administer medications as indicated:
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
What are the 5 nursing interventions?These are assessment, diagnosis, planning, implementation, and evaluation.
What are the nursing interventions for a patient?Common nursing interventions include:. Bedside care and assistance.. Administration of medication.. Postpartum support.. Feeding assistance.. Monitoring of vitals and recovery progress.. What are the nursing intervention for a patient post stroke?Nurses are expected to perform comprehensive and systematic physical assessments for all patients with stroke, including monitoring the main 5 vital signs: body temperature, blood pressure (BP), breathing effort (rate, patterns, and chest expansion), oxygen saturation, and mental status/level of consciousness.
What are the 3 nursing interventions?There are typically three different categories for nursing interventions: independent, dependent and interdependent.
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