Self-Care Deficit related to Hemiparesis / Hemiplegia (Stroke)

Self-care deficit related to hemiparesis / hemiplegia (stroke) 1

Nursing Care Plan for Stroke

Stroke is a condition that arises due to circulatory disturbances in the brain that cause the death of brain tissue that result in a person suffering from paralysis or death (Fransisca B. Batticaca).

Risk factor for stroke is 2:
1. Risk factors that can be treated / prevented:

  • Smokers.
  • Cardiovascular disease (heart fibrillation)
  • High blood pressure.
  • The increase in the number of red blood cells (polycythemia).
  • Transient ischemic attack (TIAs).

2. Risk factors that can not change:

  • Age of 65.
  • Increased blood pressure.
  • Heredity (family no stroke).
  • Ever had a stroke.
  • Race (Blacks higher)
  • Sex (males 30% more than women), DM.

Stroke symptoms that arise depending on the type of stroke.
1. Symptoms in hemorrhagic stroke:

  • Neurological deficit of sudden, preceded by prodromal symptoms comprising at rest or wake up in the morning.
  • Sometimes no loss of consciousness occurs.
  • Occurs mainly at the age of 50 years.
  • Neurological symptoms that arise depend on the severity and location of blood vessel disorders.

2. Clinical symptoms in acute stroke:

  • Facial paralysis or limb (usually hemiparesis) that arise suddenly.
  • Disorders of sensibility in the limbs (hemisensory disturbance).
  • A sudden change in mental status (confusion, delirium, lethargy, stupor, or coma).
  • Aphasia (not smooth or can not talk).
  • Dysarthria (slurred speech or slurred speech).
  • Ataxia (tungjai or limb is not exactly on target).
  • Vertigo (nausea and vomiting or headache).

Nursing Diagnosis : Self-Care Deficit (hygiene, toileting, moving, eat) related to Hemiparesis / Hemiplegia

Goal: client self-care needs are met.

Outcomes:

  • Clients can perform self-care activities in accordance with the client’s capabilities.
  • Clients can identify the source of personal / community to provide assistance as needed.

Nursing Interventions:

  1. Test capabilities and deficient levels (using a scale of 0-4) to perform day-to-day needs.
  2. Avoid doing something for patients to do their own, but provide assistance as needed.
  3. Be aware of the behavior of impulsive activity due to interference in decision making.
  4. Maintain support, assertive attitude. Give patients enough time to do the work.
  5. Give positive feedback for any work done or success.
  6. Put food and other tools on the side limbs of patients who are not ill.
  7. Customize your bed, so that the patient’s body that is not sore facing room with a sore side facing the wall.
  8. Use of personal aids, such as a combination fork blades, brushes stalk length, stalk length to pick up something from the floor; shower chair; toilet seat is rather high.
  9. Assess the patient’s ability to communicate about the need to avoid and / or the ability to use a urinal, bedpan. Bring the patient to the bathroom with a regular / specific time intervals to urinate if possible.
  10. Identification of previous bowel habit and return to the normal habits. Levels of fibrous foods, recommended to drink a lot and increase activity.

Rationale :

  1. Assist in anticipating / planning meeting individual needs.
  2. These patients may be very frightened and very dependent and despite the help given useful in preventing frustration, it is important for patients to do as much as possible for their own self-esteem to maintain and improve recovery.
  3. May indicate the need for intervention and additional monitoring to improve patient safety.
  4. Patients will require empathy but caregivers need to know that will help patients consistently.
  5. Increase feelings of self meaning. Increasing self-reliance, and encourage patients to strive continuously.
  6. Patients will be able to look for food cravings.
  7. Will be able to see if the rise / fall out of bed, can observe people coming into the room.
  8. Patients may self-handle, increase the independence and self-esteem.
  9. Maybe having a nervous breakdown bladder, can not tell his needs in the acute recovery phase, but usually can control this function returns the corresponding development of the healing process.
  10. Assessing the development of an exercise program (standalone) and assist in the prevention of constipation and constipation (long-term effects).

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Self-care deficit related to hemiparesis / hemiplegia (stroke) 2

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