Showing posts with label Stroke. Show all posts

Disturbed Sleep Pattern Nursing Care Plan for Stroke

Sleep is one of the basic human needs. Bed rest depending on the age and habits of each individual. Babies and children need more sleep than adults. In adults, bed rest, relax as well as much needed other than the actual sleep.

Get the quality and quantity of good sleep is one important part of the healing process of patients with stroke. However, sleep disturbance itself is a problem that often arises in patients with stroke. Sleep disorders can lead to frustration. Sleep disorders can make the patient tired and disturbed.

Disturbed Sleep Pattern Definition :

Disturbed Sleep pattern Time-limited disruption of sleep
Disturbed Sleep pattern

Characteristics:

Prolonged awakenings, sleep maintenance insomnia, self-induced impairment of normal pattern, sleep onset more than 30 minutes, early morning insomnia, awakening earlier or later than desired, verbal complaints of difficulty falling asleep, verbal complaints of not feeling well-rested, increased proportion of Stage 1 sleep, dissatisfaction with sleep, less than age-normed total sleep time, three or more nighttime awakenings, decreased proportion of Stages 3 and 4 sleep, decreased ability to function.

Nursing Diagnosis Disturbed Sleep Pattern Nursing Care Plan for Stroke

Disturbed Sleep Pattern related to the environment and the lack of privacy

Goal:

Patients can meet the need for sleep

Expected Outcomes:

Patients often wake up at night.
Patients find it easy to fall asleep without difficulty.
Patients can get up in the morning with a fresh and not tired.

Nursing Interventions

1. Assess patients' sleep patterns to plan treatment

2. Observation of patient medication and diet

3. Help the patient reduce the pain before sleep and the client with a comfortable position to sleep

4. Keep quiet environment, such as lowering the volume of radio & television

Rational:

Sleep habits are individual. Data collected in a comprehensive and holistic needed to decide the etiology of sleep disorders

Difficulty sleeping can be a side effect of medication

Clients say an uncomfortable position and pain are all factors that are often the cause of sleep disorders

Excessive crowd cause sleep disturbance.

Deficient Knowledge Nursing Care Plan for Stroke

Deficient Knowledge Definition :
Absence or deficiency of cognitive information related to a specific topic

Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic) Knowledge deficient related to less access to health information.

Stroke is a medical emergency that occurs when the blood flow to the brain is interrupted. This typically occurs when a blood clot blocks the flow of blood, thereby preventing the brain from getting the oxygen that it needs. Without oxygen, the brain cannot function properly and could be permanently damaged.

Nursing Diagnosis for Stroke Deficient Knowledge

Goal:
Increased knowledge of clients

Expected Outcomes:

Clients and families understand about the disease Stroke, care and treatment

Nursing Interventions Nursing Care Plan for Stroke :

1. Assessing the client's readiness and ability to learn

2. Assessing knowledge and skills of previous clients about the disease and its impact on the desire to learn.

3. Give the most important material on the client

4. Identify the main source of support and note the client's ability to learn and support the necessary behavior changes.

5. Assess the family desires to support the client's behavior change.

6. Evaluation of learning outcomes through demonstration and mentions again the material being taught.

Rational:

The learning process depends on the particular situation, social interaction, cultural and environmental values

New information is absorbed and the fact meallui previous assumptions and biases influence the transformation process

Information will be more striking if the concept is explained from the simple to the complex

Family support is needed to support changes in patient.

Self-Care Deficit Nursing Care Plan for Stroke

Self-Care Deficit Nursing Nanda Diagnosis Definition:

Impaired ability to perform or complete activities of daily living, Such as feeding, dressing, bathing, toileting.

The nurse may encounter the patient with a self-care deficit in the hospital or in the community.

Stroke Definition :

That stroke is a disease affects the blood vessels That blood supply to the brain. Without blood to supply oxygen and Nutrients and to remove waste products, brain cells begin to die Quickly. Stroke is Sometimes Called a "brain attack. Stroke is a medical emergency and can cause permanent neurological damage or even death if not promptly diagnosed and treated.

The cause of stroke is an interruption in the blood supply, with a resulting depletion of oxygen and glucose in the affected area. This reduces or abolishes IMMEDIATELY neuronal function, and also initiates the ischemic cascade the which Causes neurons to die or Be Seriously Damaged, Further impairing brain function.

Nanda Nursing Diagnosis Self-Care Deficit

related to weakness, neuromuscular disorders, decreased muscle strength, decreased muscle coordination, depression, pain, damage to the perception

Goal: The ability to care for self-rising

Expected outcomes:

a. Demonstrating changes in lifestyle to meet the needs of daily living

b. Perform self-care according to ability

c. Identify and utilize sources of aid

Nursing Interventions Self-Care Deficit Nursing Care Plan for Stroke

1. Monitor the client's skill level in caring for themselves

2. Provide assistance to the needs that really need it

3. Create an environment that allows clients to perform ADLs independently

4. Involve the family in helping clients

5. Client's motivation to perform ADLs according to ability

6. Provide aids themselves when possible

7. Collaboration: plug the DC if necessary, consultation with a occupational or physiotherapy.

Ineffective Airway Clearance Stroke Nursing Care Plan

Ineffective Airway Clearance Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Stroke

Stroke is also Referred to as a brain attack, and it Occurs Pls a blood vessel leading to the brain ruptures or gets blocked due to plaque deposits. When plaque accumulates on the wall of arteries, it is known as arthrosclerosis.

Nanda Nursing Diagnosis Ineffective Airway Clearance

related to the buildup of sputum (due to weakness, loss of cough reflex)

Goal: Patient is able to maintain a patent airway.

Expected outcomes:

a. Vesicular breath sounds

b. Normal respiratory rate

c. No signs of cyanosis and pallor

d. There is no sputum

Nursing Interventions :

1. Auscultation of breath sounds

2. Measure vital signs

3. Give the semi-Fowler position in accordance with the requirements (not conflict with other nursing problems)

4. Perform the exploitation lenders and pairs of OPA if decreased consciousness

5. When it is possible to do chest physiotherapy and breathing exercises in

6. Collaboration:

Provision of oxygenation
Laboratory: blood gas analysis, complete blood etc.
Giving medication as needed