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NCP - Self Care Deficit Neuromuscular Impairment Secondary To CVA

The patient suffered a cerebrovascular accident (CVA) or stroke, resulting in a self-care deficit from neuromuscular impairment. The nurse's diagnosis is self-care deficit due to impaired ability to perform tasks like bathing, dressing, and grooming. The short-term goal is for the patient or caregivers to identify assistance resources and understand health practices. The long-term goal is for them to demonstrate lifestyle changes to meet self-care needs. Interventions include establishing rapport, monitoring vitals, and assessing strength and motor skills to identify needed assistance.

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Hannah Batallones
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2K views1 page

NCP - Self Care Deficit Neuromuscular Impairment Secondary To CVA

The patient suffered a cerebrovascular accident (CVA) or stroke, resulting in a self-care deficit from neuromuscular impairment. The nurse's diagnosis is self-care deficit due to impaired ability to perform tasks like bathing, dressing, and grooming. The short-term goal is for the patient or caregivers to identify assistance resources and understand health practices. The long-term goal is for them to demonstrate lifestyle changes to meet self-care needs. Interventions include establishing rapport, monitoring vitals, and assessing strength and motor skills to identify needed assistance.

Uploaded by

Hannah Batallones
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Medical Diagnosis: Cerebrovascular Accident

Problem: Self Care Deficit Neuromuscular Impairment

Assessment Nursing Diagnosis Planning Interventions Rationale of Intervention Evaluation

Subjective: (none) Nursing Diagnosis Short Term: Dependent Patient or significant


After 4 hrs of nurse (none) others shall have
Objective: Self Care Deficit patient interaction, the identified personal
 with soiled clothes neuromuscular impairment patient or significant Independent resources that can
 with unsatisfying secondary to CVA others will be able to 1. Establish rapport 1. To promote provide assistance and be
appearance identify personal cooperation able to verbalized
 with minimal Scientific Explanation resources that can provide
assistance and be able to
knowledge of health care
sweating 2. Monitor vital signs 2. To have a baseline practices and be able to
 uncombed hair Self care deficit - impaired verbalize knowledge of data
ability to perform or health care practices. demonstrated
 Restlessness 3. Wear clothing with
complete task like feeding, techniques/ lifestyle
 Weakness zipper closures, basin or 3. Provides safe support
bathing/hygiene, dressing Long Term: changes to meet self-care
 Discomfort cups on personal for immobility and
and grooming or toileting After few days the patient needs or the significant
hygiene articles for other self care
activities of oneself. or significant others will brushing teeth, combing activities to promote others will be able to
be able to demonstrate perform the health care
hair, clothing that is independence.
*Cerebrovascular disease techniques/ lifestyle practices for the patient.
easily managed to dress
(CVA) or stroke refers to any changes to meet self-care
and undress
physical or structural needs.
abnormality of the brain
caused by a pathological 4. Assess client’s muscle 4. To identify/note
condition of the cerebral strength, gross and fine probable
vessels or the entire motor coordination management/plan of
cerebrovascular system. This care, severity of the
pathology either causes condition
hemorrhage from a tear of
vessel wall or impairs the 5. Determine individual 5. To identify plan of
cerebral circulation by a strengths and skills of care; to know client’s
partial or complete occlusion the client needs for assistance
of the vessel lumen with (weaknesses)
transient or permanent
effects Collaborative:
(none)

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