NURSING CARE PLAN
CEREBRAL VASCULAR ACCIDENT
Nursing Problem Nursing Diagnosis Goal Nursing Intervention Rationale Evaluation
Altered level of Altered level of Patient will I will assess the level of consciousness using a To monitor patients During
consciousness consciousness improve his Glasgow coma scale. progress hospitalization
related to brain consciousness I will examine pupil sizes and reactivity to light to patient had
tissue damage during the monitor indications of increased intracranial improved his level of
evidenced by period of pressure which may be demonstrated by pupil consciousness
patient inability to hospitalization unresponsiveness to light.
respond to stimuli. When pupils are dilated and fixed alarm the doctor
as it is an indication that there is more damage to
the brain with a lot of cerebral edema which
requires emergency management.
Vital signs - intracranial pressure, BP rises, pulse is
slow, respiration may be noisy and slow (chyne
stokes).
Temperatures rises sometimes record and report
findings.
Check limb rigidity
Ineffective Ineffective airway To promote I will suction the patient’s airway to promote airway
airway clearance related to and maintain patency
decrease in cough patency of
and swallowing patient’s I will assess the breathing pattern by checking
reflex evidenced airway until respiratory rate and any laboring in breathing. The patient’s airway
by noise breathing patient gains I will Position the patient in recumbent position patency promoted
consciousness. with the head tilted to the side to promote free and maintained
drainage of secretions. whilst in coma state
evidenced by
absence of noisy
breathing.
NURSING CARE PLAN
CEREBRAL VASCULAR ACCIDENT
I will nurse the patient in a warm, dust free and
humidified environment to prevent airway irritation
and stimulation of excessive production of secretion
Administer oxygen 4-6litres per minute to promote
adequate ventilation
Risk for Risk for nutritional To maintain I will Insert a nasal gastric tube for feeding the client
nutritional imbalance less patient’s Patient’s nutritional
imbalance than body nutritional 3 hourly feeding with semi solid balanced meal to status maintained
requirement status as per meet the body’s nutritional demands. during coma state.
related to body
patient’s inability requirement
to take in oral throughout
feed during the hospitalization.
unconscious state.
Open feeding chat to monitor the amount of feeds
and prevent nutritional imbalance more than body
requirement.
Increase fiber diet and fluid to prevent constipation
Involve the nutritionist for professional nutritional
advice
NURSING CARE PLAN
CEREBRAL VASCULAR ACCIDENT
Nursing Problem Nursing Diagnosis Goal Nursing Intervention Rationale Evaluation
Self-care deficit Self-care deficit To provide Oral care to be done at least twice a day To prevent oral thrush Patient helped to
related to coma holistic nursing and halitosis. achieve some
evidenced by care for the Bed bath daily To promote blood priority activities of
patient’s inability patient circulation patient’s daily living
to participate in throughout comfort and personal
his care. hospitalization. hygiene.
Feeding via NGT Maintain pt.’s nutritional
status
Catheterization and catheter care To prevent frequent
soiling of linen and
maintain skin integrity
2 hourly turnings Pressure area care To prevent bed sore
formation
Involve the Physiotherapist for passive exercise For rehabilitation and
maintenance of muscle
tone
To detect infections and
Risk of infection Risk of infection To prevent Vitals to be done 4 hourly especially intervene Throughout
related to the infections temperature. To prevent hypostatic hospitalization
hospital throughout 2 hourly turnings pneumonia patient had no signs
environment hospitalization of infections
being an To prevent ascending
infectious place IV care infection
and patient’s To prevent eye
condition Eye care infections
To prevent urinary tract
Catheter care infections (UTIs)
NURSING CARE PLAN
CEREBRAL VASCULAR ACCIDENT
Nursing Problem Nursing Diagnosis Goal Nursing Intervention Rationale Evaluation
Aseptic techniques when doing invasive To Prevent infection
procedures such as IV access and Injection giving
Giving of prescribed antibiotics e.g. benzyl For prophylaxis
penicillin
knowledge knowledge deficit Patients to be Assess level of knowledge To give appropriate During
deficit related to disease knowledgeable information hospitalization
process evidenced of his/her Explain the disease process using a simple To ensure he/she patient was
by patient asking a condition language to the patient and relatives understands knowledgeable of his
lot of questions during condition evidenced
hospitalization Explain the investigation and treatment modality To promote co-operation by pt not asking a lot
of questions
Allow patient, relatives to vent out their To allay anxiety
concern and answer accordingly and refer where
not sure
Involve significant others e.g. relatives in the For continuity of care
care
Educate the patient on possible complications For patient’s awareness,
detection and treatment
of any complications.
Explain to the relatives about what is happening To allay anxiety and build
to the patient i.e. the level of consciousness after their confidence in the
every assessment and that everything possible is health care team.
being done to help the pt gain his conscious
NURSING CARE PLAN
CEREBRAL VASCULAR ACCIDENT
OTHER NURSING PROBLEMS
a) Risk of injury
b) Risk of pressure sore formation
c) Impaired verbal communication
Thank you so much
