NURSING PROCESS APPLICATION IN STROKE.pptx

The American Nurses Association (ANA) defines the nursing process as “the essential core of practice for the registered nurse to deliver holistic, patient-focused care.
Or
Defined as a systematic approach to care, using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EBP) recommendations, and nursing intuition. 
It is considered the framework upon which all nursing care is based.
Nursing Diagnosis for Care Plans
This section is the list or database of the common NANDA nursing diagnosis examples
DIAGNOSTIC LABEL
Activity Intolerance
Acute Pain
Anxiety
Chronic Pain
Constipation
Decreased Cardiac Output
Deficient Fluid Volume
Deficient Knowledge
Diarrhea
Excess Fluid Volume
Fatigue
Fear
Grieving
Hopelessness
Hyperthermia
Hypothermia
Imbalanced Nutrition: Less Than Body Requirements
Impaired Gas Exchange
Impaired Tissue (Skin) Integrity
Impaired Urinary Elimination
Ineffective Airway Clearance
Ineffective Breathing Pattern
Ineffective Tissue Perfusion
Risk for Falls
Risk for Impaired Skin Integrity
Risk for Infection
Risk for Injury
Risk for Unstable Blood Glucose Level
Patient problem present during A nursing assessment is known as A problem-focused diagnosis
Risk factors require intervention from the nurse and healthcare team prior to A real problem developing
Improve the overall well-being of an individual, family, or community
A cluster/group of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions
A possible diagnosis is a statement about a health problem that the client might have now, but the nurse doesn’t yet have enough information to make an actual diagnosis.
An example of a possible diagnosis is: Possible fluid volume deficit in case of frequent vomiting for three days .
Cerebrovascular accident (CVA), also known as stroke, acute ischemic stroke, cerebral infarction, or brain attack.
Definition:
It is the sudden impairment of cerebral circulation in one or more blood vessels supplying the brain caused by hemorrhage from a tear in the vessel wall or impairs cerebral circulation by partial or complete occlusion of the vessel lumen
Strokes can be classified into 2 main categories:
Ischemic strokes. These are strokes caused by blockage of an artery (or, in rare instances, a vein). About 87% of all strokes are ischemic.
Hemorrhagic stroke. These are strokes caused by bleeding. About 13% of all strokes are hemorrhagic.
2 main categories, Ischemic strokes :
Thrombotic strokes. These are caused by a blood clot that develops in the blood vessels inside the brain.
Embolic strokes. These are caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain through the bloodstream.
2 main categories, Hemorrhagic strokes”
Intracerebral hemorrhage.
 Bleeding is from the blood vessels within the brain.
Subarachnoid hemorrhage.

1. NURSING PROCESS APPLICATION IN STROKE INCLUDING SOME BASICS. MRS.WINCY.C PROFESSOR.

2. The American Nurses Association (ANA) defines the nursing process as “ the essential core of practice for the registered nurse to deliver holistic, patient-focused care . Or Defined as a systematic approach to care, using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EBP) recommendations, and nursing intuition.  WHAT IS NURSING PROCESS IN SIMPLE WORDS?

3. WHAT IS NURSING PROCESS IN SIMPLE WORDS? The nursing process is a series of steps nurses take to It is considered the framework upon which all nursing care is based.

4. WHEN WAS THE NURSING PROCESS DEVELOPED?

5. WHAT IS THE PURPOSE OF THE NURSING PROCESS?

6. WHAT ARE THE IMPORTANT STEPS/COMPONENTS OF NURSING PROCESS DEVELOPED?

7. STEPS/PHASES/ COMPONENTS OF NURSING PROCESS.

8. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION Do and document EVALUATION Ask yourself: what data is collected and why do I think this as a problem? Gathering the supportrive data . Subjective Data ( symptom) 1. History Objective Data (sign) Verifying previous documents Dx-diagnosis Sx -symptoms Rx-prescription Physical examination Neurological examination Confirming with the patient party (with a double check) Ask yourself: “What is the problem?”  Clinical judgement/problem statement written by the nurse. PES FORMAT PROBLEM /Diagnostic label- Ineffective cerebral tissue perfusion . ETIOLOGY /related or risk factors – hemorrhage ( Heamorrhagic stroke) or clot in a cerebral vessel (Ischemic stroke) . SIGN AND SYMPTOMS /defining characteristics - right-sided weakness, facial asymmetry, and difficulty speaking . PARTS OF A DIAGNOSTIC LABEL usually has two parts : Ask: what the nurse hopes to achieve by implementing the nursing interventions derived from the client’s nursing diagnoses? Goals and expected outcomes must be  measurable  and  client-centered.  Goals can be short-term or long-term. Short-term goal:  It is a statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days. Long-term goal: Indicates an objective to be completed over a longer period, usually over weeks or months Frame a statement of goal with the client will maintain or manage/identify etc According to Hamilton and Price (2013), goals should be  SMART . SMART goals analysis strategy stands for – Specific, Measurable, Attainable, Realistic, and Time-Bound goals. Ask: How to manage the problem? STEPS: Setting priorities Establishing goals Selecting nursing interventions Documenting the plan of care METHOD OF DOCUMENTING THE NURSING INTERVENTIONS. Written under THREE division 1. Observation/Diagnostic plans 2. Task/ Treatment oriented plans 3. teaching/educational plans Be specific in planning and thorough Revise according to the evaluation report everyday. Ask: why should I select this nursing intervention? It provides a critical thinking statement that explains the underlying reasoning for nurses’ interventions. Ex: Monitoring the vital signs enables the nurse to plan further specific nursing intervention Or Pain assessment give an evidence for the severity of pain 8/10 Ask yourself: what will I document ? Putting the plan into action This phase includes not only doing but also documenting the provided nursing care with date and time. METHOD OF DOCUMENTING THE NURSING Iimplimentations /actions . Written under THREE division 1. Observation/Diagnostic plans 2. Task/ Treatment oriented plans 3. teaching/educational plans Criteria: Narrative note Not the restatements of your plan in past tense Doesnot need to address every plan Donot number or leave space. Ask yourself: Did the plan work/ did I accomplish my goal? POSSIBLE OUTCOMES : There are three possible outcomes,  Met Ongoing Not Met The possible patient outcomes are generally explained under three terms: 1. the patient’s condition improved , 2.the patient’s condition stabilized, and 3. the patient’s condition worsened. QUALIFIER Deficient FOCUS OF THE DIAGNOSIS .  Fluid volume Imbalanced Nutrition: Less Than Body Requirements Impaired Gas Exchange Ineffective Tissue Perfusion Risk for Injury

9. Nursing Diagnosis for Care Plans This section is the list or database of the common NANDA nursing diagnosis examples DIAGNOSTIC LABEL Activity Intolerance Acute Pain Anxiety Chronic Pain Constipation Decreased Cardiac Output Deficient Fluid Volume Deficient Knowledge Diarrhea Excess Fluid Volume Fatigue Fear Grieving Hopelessness Hyperthermia Hypothermia Imbalanced Nutrition: Less Than Body Requirements Impaired Gas Exchange Impaired Tissue (Skin) Integrity Impaired Urinary Elimination Ineffective Airway Clearance Ineffective Breathing Pattern Ineffective Tissue Perfusion Risk for Falls Risk for Impaired Skin Integrity Risk for Infection Risk for Injury Risk for Unstable Blood Glucose Level

10. TYPES OF NURSING DIAGNOSIS There are 5 types of nursing diagnoses.  

11. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION Do and document EVALUATION Ask yourself: what data is collected and why do I think this as a problem? Gathering the supportrive data . Subjective Data ( symptom) 1. History Objective Data (sign) Verifying previous documents Dx-diagnosis Sx -symptoms Rx-prescription Physical examination Neurological examination Confirming with the patient party (with a double check) Ask yourself: “What is the problem?”  Clinical judgement/problem statement written by the nurse. PES FORMAT PROBLEM /Diagnostic label- Ineffective cerebral tissue perfusion . ETIOLOGY /related or risk factors – hemorrhage ( Heamorrhagic stroke) or clot in a cerebral vessel (Ischemic stroke) . SIGN AND SYMPTOMS /defining characteristics - right-sided weakness, facial asymmetry, and difficulty speaking . PARTS OF A DIAGNOSTIC LABEL usually has two parts : Ask: what the nurse hopes to achieve by implementing the nursing interventions derived from the client’s nursing diagnoses? Goals and expected outcomes must be  measurable  and  client-centered.  Goals can be short-term or long-term. Short-term goal:  It is a statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days. Long-term goal: Indicates an objective to be completed over a longer period, usually over weeks or months Frame a statement of goal with the client will maintain or manage/identify etc According to Hamilton and Price (2013), goals should be  SMART . SMART goals analysis strategy stands for – Specific, Measurable, Attainable, Realistic, and Time-Bound goals. Ask: How to manage the problem? STEPS: Setting priorities Establishing goals Selecting nursing interventions Documenting the plan of care METHOD OF DOCUMENTING THE NURSING INTERVENTIONS. Written under THREE division 1. Observation/Diagnostic plans 2. Task/ Treatment oriented plans 3. teaching/educational plans Be specific in planning and thorough Revise according to the evaluation report everyday. Ask: why should I select this nursing intervention? It provides a critical thinking statement that explains the underlying reasoning for nurses’ interventions. Ex: Monitoring the vital signs enables the nurse to plan further specific nursing intervention Or Pain assessment give an evidence for the severity of pain 8/10 Ask yourself: what will I document ? Putting the plan into action This phase includes not only doing but also documenting the provided nursing care with date and time. METHOD OF DOCUMENTING THE NURSING Iimplimentations /actions . Written under THREE division 1. Observation/Diagnostic plans 2. Task/ Treatment oriented plans 3. teaching/educational plans Criteria: Narrative note Not the restatements of your plan in past tense Doesnot need to address every plan Donot number or leave space. Ask yourself: Did the plan work/ did I accomplish my goal? POSSIBLE OUTCOMES : There are three possible outcomes,  Met Ongoing Not Met The possible patient outcomes are generally explained under three terms: 1. the patient’s condition improved , 2.the patient’s condition stabilized, and 3. the patient’s condition worsened. QUALIFIER Deficient FOCUS OF THE DIAGNOSIS .  Fluid volume Imbalanced Nutrition: Less Than Body Requirements Impaired Gas Exchange Ineffective Tissue Perfusion Risk for Injury

12. Dx-diagnosis Sx -symptoms Rx-prescription

13. AN OVERVIEW OF STROKE …

14. T Y P E S

15. MRS. FLORENCE , 73-YEAR OLD FEMALE WITH STROKE CASE SCENARIO

16. CASE SCENARIO Mrs. Florence , 73-year old female presents to the ED with complaints of right-sided weakness and difficulty speaking. The patient’s son said he was having lunch with his mom when she began having problems holding her fork and using her right arm . When he asked his mom what was wrong, she had difficulty finding words and was unable to properly formulate sentences . The patient’s son also noticed her face appeared asymmetrical . Upon assessment, the patient appears drowsy . She is unable to answer orientation questions and engages in endless word-searching, repeating sentences such as – “you… the… the…” The patient is able to obey commands on the left side , but can only minimally move her right arm and leg. She can smile and raise her eyebrows, but her face is asymmetrical and the right side is less mobile than the left. Her gaze is normal and partial hemianopia is noted in the right visual field.  The patient’s blood work is within normal limits. A CT scan of the head is performed, confirming the presence of cerebral infarction. The patient is admitted to the hospital for a  Cerebrovascular Accident (CVA/Stroke) .

17. NATIONAL INSTITUTES OF HEALTH STROKE SCALE(NIHSS) RESULT SUMMARY: 10 points out of 42 in NIH Stroke Scale IMPRESSION: Moderate Stroke

18. Dysarthria is a motor speech disorder in which the muscles used to produce speech are damaged, paralyzed, or weak. A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.

19. PROBLEM IDENTIFICATION Right-sided weakness and difficulty speaking. Repeating sentences such as – “you… the… the…” She is unable to answer orientation questions Engages in endless word-searching She had difficulty finding words and was unable to properly formulate sentences. Having problems holding her fork and using her right arm . Her face appeared asymmetrical . The patient appears drowsy . The patient is able to obey commands on the left side , but can only minimally move her right arm and leg. She can smile and raise her eyebrows , but her face is asymmetrical and the right side is less mobile than the left. Her gaze is normal and partial hemianopia is noted in the right visual field.  Aphasia and dysarthria

20. APPLICATION OF NURSING PROCESS

21. ACTUAL PROBLEMS IN STROKE

22. Actual problems in stroke ACTUAL PROBLEMS IN STROKE

23. POTENTIAL PROBLEMS IN STROKE

24. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION Subjective Data: The son of Mrs. Florence says that, “ my mom has right-sided weakness, drowsiness and difficulty speaking from 2pm ”. Objective Data: The patient has right-sided weakness, alterd level of consciousness( drowsiness),facial asymmetry, and difficulty speaking. CT scan confirms the presence of a cerebral infarction. Total NIHSS score is 10/42 LOC (DROWSY) (1) and LOC ON COMMAND(OBEYS ONE COMMAND (1 ) Ineffective Tissue Perfusion related to interruption of blood flow to the brain secondary to a cerebrovascular accident (CVA) as evidenced by neurological deficits, altered level of consciousness(drowsy), and/or abnormal diagnostic(CT scan) tests . Sh ort-term goal:  The client will maintain the normal cerebral tissue perfusion including Stable vital signs . improved LOC, cognition, and motor and sensory functions . with in 8 hours of nursing care Long-term goal: The patient will show the improvement in the cerebral tissue perfusion including level of consciousness and ability to obey the both commands but she will show the readiness to modify her lifestyle within few months . DIAGNOSTIC/OBSERVATIONAL INTERVENTIONS OR PLANS Check hemodynamic studies. Monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, Check rapid changes or continued shifts in mental status, Evaluate motor reaction to simple commands, noting purposeful and non-purposeful movement, Evaluate verbal reaction, Monitor higher functions, as well as speech, if the client is alert. Monitor cerebral perfusion pressure (CPP) and Measure the client’s ICP. Keep an eye on the patient’s diagnostic tests results, such as CT scans or MRIs, for changes in the size or location of the stroke, Assess the patient’s response to drugs and oxygen therapy, including changes in blood pressure, oxygen saturation, and neurological condition. and Document limb movement and note right and left sides individually. Observing the hemodynamics ,CPP,ICP and neurological , sensory impairment communication ability will provide a clear picture to the nurse to plan and implement further nursing care to increase the cerebral tissue perfusion in the client. On assessment the client’s vital signs are as follows ; BP 172/90mmhg; Temp 98.3df; HR 118bts/m; RR 22brths/m; O2 Sat 95%. . .  CPP is 50 mmHg (decreased ) and ICP is 20 MmHg (increased) shows the ischemic injury, Symptoms of a poor cerebral tissue include loss of consciousness (drowsiness) able to obey only one command at a time ,sudden weakness in the right side , face appeared asymmetrical. appeared drowsy, unable to communicate and partial hemianopia in the right side are found . #1 CVA/Stroke Nursing Care Plan – Ineffective Tissue Perfusion

25. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION TREATMENT /TASK INTERVENTIONS OR PLANS Positioning the patient in a way that promotes blood flow to the brain can help improve cerebral perfusion, Elevate the head of the bed to 30 degrees .Administer oxygen therapy as ordered(10-15L/min),Provide adequate oral fluids to drink,Administer isotonic saline without dextrose iv fluids(  0.9% Normal Saline (0.9% NaCl) , Encourage mobility and ambulation as appropriate Administer medications as ordered, such as antiplatelet agents ( aspirin, 50-325 mg /day ), thrombolytics(   alteplase, 0.9 mg/kg  ) as per order. Supplemental oxygen, elevation of the head end of the bed, increasing the physical mobility thrombolytics and antiplatelet drugs will reduce the blood clotting and improve the cerebral tissue perfusion. The client is placed in a comfortable position with head elevation at less than 30 degree ,oxygen is administered through a non breather mask about 12l/m, iv fluid 0.9% NaCl is infused and thrombolytic agent is administered intravenously 100mg/day as per doctor’s order. #1 CVA/Stroke Nursing Care Plan – Ineffective Tissue Perfusion

26. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION . Teaching interventions or plans Teach the client to increase the rate and depth of breathing, Educate to maintain adequate hydration is important for improving cerebral perfusion, Motivate the client to increase the physical mobility. Counsel the client to do life style modifications, and teach the client to avoid excess stress Teaching the client regarding breathing exercises, physical activity ,hydration and stress free life style will enable the client to maintain normal tissue perfusion. The client was encouraged to practice fast breathing technique progressively, the family members took initiation to frequently hydrating the patient with some oral fluids like water, juices, etc. she started to walk with assistance in the right side and shown readiness to modify the life style including water intake, physical activity, avoid processed foods and stress adaptive techniques. 1.Short term goal Goal is partially met With in the 8 hours of patient care the patient demonstrated an improvement in LOC like drowsiness and obeying both the commands correctly. right-sided weakness and able to verbally communicate to some extend than the earlier state. NIHS score for language (aphasia ) is still remains 1 but dysarthria is improved from 1 to 0 . Total NIHS score is 9/42 2. Long term goal Goal is partially met  The patient shown sign of improvement in the level of consciousness and ability to obey the both commands but she assured her readiness to maintain normal tissue perfusion in the future with her medications and lifestyle modifications within few months . #1 CVA/Stroke Nursing Care Plan – Ineffective Tissue Perfusion

27. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION Subjective Data: The son of Mrs. Florence says that, “ my mom has right-sided weakness and difficulty speaking from 2pm ”. Objective Data: The patient has right-sided weakness, facial asymmetry, and difficulty speaking. CT scan confirms the presence of a cerebral infarction. Total NIHSS score is 10/42 Mild to moderate dysarthria(1) and mild to moderate aphasia(1 ) Impaired verbal communication related to hemorrhage ( Heamorrhagic stroke) or clot in a cerebral vessel (Ischemic stroke) as evidenced by right-sided weakness, facial asymmetry, and difficulty speaking. Short-term goal:  By the end of the shift, the patient will demonstrate an improvement in speaking ability and demonstrate equal bilateral motor strength. . Long-term goal: The patient will return to baseline and experience no residual neurological dysfunction . Diagnostic interventions or plans Perform physical and neurological examination to identify the facial asymmetry and muscular weakness Assess higher functions, including speech. Use the National Institutes of Health Stroke Scale (NIHSS)  for assessing neurologic impairment Assess the client for aphasia and dysarthria and Differentiate and check for fluency. Point to objects and ask the client to name them . Ask the client to produce simple sounds (“dog,” “meow,” “Shh”) to check the articulation and Assess the client for signs of  depression . Enables the nurse to determine the exact cause for the speech difficulty, Changes in cognition and speech content indicate location and degree of cerebral involvement and may indicate deterioration or increased ICP. Also helps to rule out depression due to aphasia . On assessment Mrs. Florence has facial asymmetry, Right-sided weakness and difficulty speaking, unable to answer orientation questions, engages in endless word-searching, Repeating sentences such as – “you… the… the…” The clients ability to speech is clinically assessed by using National Institutes of Health Stroke Scale (NIHSS)  .the result is Total NIHSS score is 10/42. Mild to moderate dysarthria(1) and mild to moderate aphasia(1). On observation she couldn't articulate and had fluency issues and She was bit depressed on being unable to communicate with her family members . #1 CVA/Stroke Nursing Care Plan – Impaired verbal communication

28. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION Treatment oriented interventions Ask the client to write their name and a short sentence. If unable to write, have the client read a short sentence. Write a notice at the nurses’ station and the client’s room about speech impairment. Talk directly to the client, speaking slowly and distinctly. Gain the client’s attention when speaking. Phrase questions to be answered simply by yes or no. Progress in complexity as the client responds. Speak in normal tones and avoid talking too fast. Give the client ample time to respond . Avoid pressing for a response. Use gestures or related photographs to enhance comprehension. Discuss familiar topics (e.g., weather, family, hobbies, jobs). Eliminate extraneous noise and stimuli as necessary. Consult and Collaborate with a speech therapist and a physiotherapist to improve the right sided weakness and to improve the speech. A comprehensive multidisciplinary plan with meaningful conversation, Noise free environment speech and physio therapy will improve the patient’s communication ability.. The client was encouraged and motivated to improve her verbal communication and encouraged her to ventilate her emotions orally and by gestures . Used simple sentences and words to repeat ,some pictures of fruits animals to read she was able to do moderately , frequently asked some orientation questions on her name,age,time,place it helped her to enhance her ability to articulate. Noise free environment helped her so much to be calm and focus on improving the vocabulary practice without any frustrations . Family members also actively collaborated with the speech therapist and physiotherapist to increase the facial muscle strength. #1 CVA/Stroke Nursing Care Plan – Ineffective cerebral tissue perfusion

29. ASSESSMENT NURSING DIAGNOSIS NURSING GOAL/OBJECTIVE PLANNING/NSG INTERVENTION RATIONAL IMPLIMENTATION EVALUATION Teaching the client Encourage significant others (SO) to continue communicating with the client: reading mail and discussing family happenings even if the client cannot respond appropriately. Educate the family members need to continue talking to clients to reduce the client’s  isolation , promote effective communication, and maintain a sense of connectedness with the family.  Teach techniques to improve speech by Asking to talk slowly and say each word clearly. Encouraging them to speak in short phrases. If verbal communication is difficult, asking the patient to write a message or draw a picture. Encouraging the family members to help the client to establish interesting conversation and keeping the client engaged by a family members will help to rid off the depression, loneliness and progressively improve the ability to speak fluently. The family members and friends played very vital role in keeping the client emotionally warm, engaged throughout, client also practiced the techniques taught her to do .these interventions helped the client to regain her normal ability to communicate . 1.Short term goal Goal is partially met By the end of the shift the patient demonstrated an improvement in right-sided weakness and able to verbally communicate to some extend than the earlier state. NIHS score for language (aphasia ) is still remains 1 but dysarthria is improved from 1 to 0 . Total NIHS score is 9/42 2. Long term goal Goal is partially met  The patient shown some evidence of improvement in her verbal communication and she will successfully continue demonstrate further improvement in aphasia and able to communicate verbally without any hindrance in the fluency and articulation of words . #1 CVA/Stroke Nursing Care Plan – Ineffective cerebral tissue perfusion