NANDA Definition : Impaired ability to perform or complete activities of daily living, such as feeding, dressing, bathing, toileting.
A stroke is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused by a blood vessel that breaks and bleeds into the brain. "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly interrupted.
Symptoms of a stroke can include:
- A numb or weak feeling in the face, arm or leg
- Trouble speaking or understanding
- Unexplained dizziness
- Blurred or poor vision in one or both eyes
- Loss of balance or an unexplained fall
- Difficulty swallowing
- Headache (usually severe or of abrupt onset) or unexplained change in the pattern of headaches
- Confusion
Nursing Diagnosis for Stroke : Self-Care Deficit
May be related to
- Pain/discomfort
- Depression
- Perceptual/cognitive impairment
- Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination
Expected outcomes:
- Clients can perform self-care activities in accordance with the client's capabilities.
- Clients can identify the source of personal / community to provide assistance as needed.
Nursing Interventions and Rationale :
1. Test capabilities and deficient levels (using a scale of 0-4) to perform daily needs.
R: Assist in anticipating / planning needs individually.
2. Avoid doing things for the patient, do the patients themselves, but provide assistance as needed.
R: The patient may be very frightened and very dependent and despite the help given useful in preventing frustration, it is important for patients to do as much as possible for themselves to maintain self-esteem and improve recovery.
3. Be aware of the behavior of impulsive activity because of impaired decision-making.
R: May indicate need for intervention and monitoring to enhance patient safety.
4. Maintain support, assertive attitude. Give the patient enough time to do their job.
R: Patient will need empathy but caregivers need to know that will help patients consistently.
5. Give positive feedback for any work done or success.
R: Increased feelings of self-significance. Increasing independence, and encourage patients to seek a sustainable manner.
6. Use personal assistive devices, such as a combination of blade fork, brush stem length, stem length to pick up something from the floor; seat shower; toilet seat a bit high.
R: Patients can handle self, increasing self-reliance and self-esteem.
7. Assess the patient's ability to communicate about the need to avoid and / or the ability to use a urinal, bedpan. Bring the patient to the bathroom regularly / intervals to urinate if possible.
R: Maybe having a nervous breakdown bladder, can not tell his needs in the acute recovery phase, but usually can control this function again with the development of the healing process.
8. Identify the previous defecation habits and return to the normal habits. Levels of fibrous foods, recommended to drink a lot and increase activity.
R: Assessing the development of an exercise program (standalone) and assist in the prevention of constipation (long-term effects).
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