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Nursing Diagnosis and Interventions for Non Hemorrhagic Stroke

 

Nursing Diagnosis for Non Hemorrhagic Stroke :

  1. Ineffective Tissue Perfusion :  cerebral related to decreased brain oxygen
  2. Imbalanced Nutrition: Less Than Body Requirements related to inability to absorb nutrients
  3. Impaired Physical Mobility related to decrease muscle strength
  4. Risk for Impaired Skin Integrity related to risk factor : damp
  5. Impaired Verbal Communication related to neuromuscular damage, speech central damage

 


Nursing Interventions for Non Hemorrhagic Stroke

No.

Nursing Diagnosis

Goal (NOC)

Interventions (NIC)

Rationale

1.

Ineffective Tissue Perfusion :  cerebral related to decreased brain oxygen

 

Tissue perfusion can be achieved optimally

 

Expected Outcome :

·      Able to maintain level of consciousness

·      Sensory and motor function getting better

 

1.   Monitor vital signs hourly and record the result

2.   Assess motor response to simple commands

3.   Monitor neurological status regularly

4.   Encourage active/passive leg exercises

5.   Collaboration: drug delivery according to indication

 

1.      An increase in systemic blood pressure followed by a decrease in diastolic blood pressure is a sign of increased ICP.

2.      Irregular breathing indicates an increase in ICP

3.      Able to determine the level of motor response of the patient

4.      Prevent/reduce atelectasis

5.      Reduces venous static

6.      Reduce the risk of complications

 

2.

 Imbalanced Nutrition: Less Than Body Requirements related to inability to absorb nutrients

 

1.   Nutritional status

2.   Food intake

3.   Fluids and nutrients

 

Expected Outcomes :

·     Explain the components of diet closeness

·     Report adequacy nutritional level

·     Laboratory values ​​(eg: transferrin, albumen and electrolyte

·     Tolerance to good nutrition recommended.

 

1.    Disturbance management food

2.    Nutrition management

3.    Help to gain weight

 

Nursing activities:

1.    Determine the client's motivation to change eating habits

2.    Know the client's favorite food

3.    Refer to a doctor to determine the cause of nutritional changes

4.    Help eat according to client's needs

5.    Create an environment that fun to eat

 

 

1.    The client's motivation influences the change in nutrition

2.    The client's favorite food to facilitate the provision of nutrition

3.    Refer to the doctor to find out the changes in the client and for the healing process

4.    Help eat to know nutritional changes

5.    Creating an environment for the comfort of the client's rest as well as for tranquility in the room.

 

 

3.

Impaired Physical Mobility related to decrease muscle strength

 

Show increased mobility, indicated by the following indicators (state the value 1 – 5) : dependent (not participating) requires the help of others or the tool requires the help of others, independent with the help of assistive devices or fully independent).

 

Expected Outcomes :

·     Demonstrate the correct use of assistive devices with supervision.

·     Asking for assistance in mobilizing activities if needed.

·     Use a wheelchair effectively.

 

1.    Activity therapy, ambulation

2.    Activity therapy, joint mobility.

3.    Position change

 

Nursing activities:

1.    Teach clients about the use of tools

2.    Assist mobility.

3.    Teach and assist clients in the transfer process.

4.    Provide positive reinforcement during activities.

5.    Support ROM training techniques

6.    Collaboration with the medical team on client mobility

 

1.         Teach clients about and monitor the use of mobility aids clients more easily.

2.         Helping clients in the transfer process will help clients practice in this way.

3.         Giving positive reinforcement during the activity will help the client to be enthusiastic in training.

4.         Accelerate the client in mobilization and relax the muscles

5.         Knowing the client's mobilization development after ROM exercises

6.         Collaboration with the medical team can help improve patient mobility such as collaboration with doctors

 

4.

Risk for Impaired Skin Integrity related to risk factor : damp

 

Tissue Integrity : Skin and Mucous Membranes

 

Expected Outcomes :

·     Good skin integrity can be maintained (sensation, elasticity, temperature, hydration, pigmentation)

·     There are no wounds / lesions on the skin

·     Demonstrate understanding in the skin repair process and prevent repeated injury

·     Able to protect the skin and maintain skin moisture and natural care

 

1.    Advise the patient to wear loose clothing

2.    Avoid wrinkles on the bed

3.    Keep the skin clean to keep it clean and dry

4.    Patient mobilization (change patient position) every two hours

5.    Monitor the skin for redness

6.    Apply lotion or oil/baby oil on stressed areas

7.    Collaboration giving antibiotics as indicated

 

1.    Skin may be damp and may feel unable to rest or need to move

2.    Reduce the risk of infection on the skin

3.    The first way to prevent infection

4.    Prevent further complications

5.    Knowing the development of the occurrence of skin infections

6.    Reduce exposure to infectious germs on the skin

7.    Reduce the risk of infection

 

5.

Impaired Verbal Communication related to neuromuscular damage, speech central damage

 

Good communication

 

Expected Outcomes :

·     Clients can express feelings

·     Understanding the intentions and conversations of others

·     The patient's speech can be understood

 

1.   Communicate with reasonable, clear, simple language and if necessary repeated

2.   Listen carefully when the patient starts talking

3.   Stand in the patient's field of view when speaking

4.   Exercise your speech muscles optimally

5.   Involve the family in practicing verbal communication with the patient

6.   Collaboration with speech therapists

 

1.    Checking the client's communication whether it really can't do communication

2.    Knowing how the client's communication skills

3.    Knowing the degree / level of communication skills

4.    Reduce the occurrence of further complications

5.    Families know & are able to demonstrate how to practice verbal communication to clients without the help of nurses

6.    Knowing the development of the client's verbal communication

 

Stroke - Physical Examination (B1-B6) - Breathing, Blood, Brain, Bladder, Bowel and Bone

Stroke - Causes, Risk Factors, Symptoms and Problems that Occur After a Stroke

 

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