Nursing diagnosis for Cerebrovascular Accident (CVA)

nursing-careplans.com- Nursing care plan for Cerebrovascular Accident (CVA), Nursing diagnosis for Cerebrovascular Accident (CVA): ineffective Coping related to situational crises, vulnerability, cognitive perceptual changes. This article discusses the Nursing care plan for Cerebrovascular Accident (CVA) and Nursing diagnosis for Cerebrovascular Accident (CVA)

Possibly evidenced by
Inappropriate use of defense mechanisms
Inability to cope or difficulty asking for help
Change in usual communication patterns
Inability to meet basic needs or role expectations
Difficulty problem-solving
Nursing diagnosis for Cerebrovascular Accident (CVA)


Desired Outcomes/Evaluation Criteria—Client Will
Coping
Verbalize acceptance of self in situation.
Talk or communicate with SO about situation and changes that have occurred.
Verbalize awareness of own coping abilities.
Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.

Nursing intervention with rationale
1. Assess extent of altered perception and related degree of disability. Determine Functional Independence Measure score.
Rationale: Determination of individual factors aids in developing plan of care, choice of interventions, and discharge expectations.

2. Identify meaning of the loss and dysfunction or change to client. Note ability to understand events and provide realistic appraisal of situation.
Rationale: Independence is highly valued in American society, but is not as significant in some other cultures. Some clients accept and manage altered function effectively with little adjustment, whereas others have considerable difficulty recognizing and adjusting to deficits. In order to provide meaningful support and appropriate problem-solving, healthcare providers need to understand the meaning of the stroke and limitations to the client.

3. Determine outside stressors, including family, work, social, and future nursing and healthcare needs.
Rationale: Helps identify specific needs, provides opportunity to offer information and support and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination.

4. Encourage client to express feelings, including hostility or anger, denial, depression, and sense of disconnectedness.
Rationale: Demonstrates acceptance of and assists client in recognizing and beginning to deal with these feelings.

5. Note whether client refers to affected side as “it” or denies affected side and says it is “dead.”
Rationale: Suggests rejection of body part or negative feelings about body image and abilities, indicating need for intervention and emotional support.

6. Acknowledge statement of feelings about betrayal of body; remain matter-of-fact about reality that client can still use unaffected side and learn to control affected side. Use words such as weak, affected, and right-left, that incorporate that side as part of the whole body.
Rationale: Helps client see that the nurse accepts both sides as part of the whole individual. Allows client to feel hopeful and begin to accept current situation.

7. Identify previous methods of dealing with life problems. Determine presence and quality of support systems.
Rationale: Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources.

8. Emphasize and provide positive I-messages for small gains either in recovery of function or independence.
Rationale: Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense of progress.

9. Support behaviors or efforts such as increased interest and participation in rehabilitation activities.
Rationale: Suggests possible adaptation to changes and understanding about own role in future lifestyle.

10. Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, and withdrawal.
Rationale: May indicate onset of depression (common aftereffect of stroke), which may require further evaluation and intervention.

Tweet