NCP CVA Self Care Deficit

Medical Diagnosis: Cerebrovascular Accident Problem: Self Care Deficit RT Musculoskeletal Impairment Assessment Subjective: (none) Objective:  

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Nursing Diagnosis Self Care Deficit R/t musculoskeletal impairment secondary to CVA

Scientific Explanation Motor deficit are the most obvious effect of  stroke. Symptoms are caused by destruction of motor neurons in the pyramidal pathways (nerve fibers in the brain and passing through the spinal cord to the motor tract.) One of  those symptoms could be inability to perform ADLS.

Planning Short Term: After 4 hrs of NI, pt will be able to identify personal resources that can provide assistance and be able to verbalize knowledge of  health care practices.

Long Term: After 3 days of NI, pt. will demonstrate techniques/ lifestyle changes to meet selfcare needs

Interventions

Rationale

1. establish rapport 2. monitor vital signs 3. Assess for type and severity of  immobility impairment, muscle flaccidity, spasticity and coordination, ability to walk, sit, move in bed perform

1. to promote cooperation 2. to have a baseline data 3. Provides data regarding mobility and ability to perform activities with in limitations without injury or frustrations.

4. passive ROM to all limbs and progress to assistive and then active ROM in all joints four times a day

4. promotes circulation, muscle tone,  joint flexibility, prevents contractures and weakness

5. use assistive devices as appropriate for ambulation, clothing with zipper closures, suction cups on personal hygiene

5. Provides safe support for immobility immobility and other self care activities to promote independence.

Evaluation Short Term: Pt shall have identified personal resources that can provide assistance and be able to verbalized knowledge of health care practices.

Long Term: Pt shall have demonstrated techniques/ lifestyle changes to meet selfcare needs

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articles for brushing teeth, combing hair, clothing that is easily managed to dress and undress

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