nursing care plan for CVA?

Question

If the client's chief complaints are weakness and dizziness, what nursing diagnosis is suited and what is the rationale behind them? also, what are the possible nursing interventions for these complaints?

The client doesn't have paralysis, only body weakness to the point that she's not able to feed and bath herself. She can't also tolerate sitting and standing because of vertigo and disequilibrium. She also has difficulty in hearing and diplopia.

Answer 1

impaired physical mobility secondary to cva.
self-care deficit:Bathing/feeding related to nueromuscular impairment.
activity intolerance rel. to generalized weakness.
interventions:assess pt. respiratory status(respiration, pulse,b/p) before activity - this affects heart rate when pt. moves in bed.
provide bedside commode as indicated to reduce energy expenditure.
observe & document response to activity- close monitoring serves as a guide of optimal progression of activity.

Answer 2

Depending on the age of your client, it is difficult to give the right advice. Has or can your client attend rehabilitation? If you have a geriatric client, hence it is Nursing Home if no-one can care for long term. There is medication that can help with the vertigo.
The diplopia can either be from the CVA or vertigo. This can subside further down the track.
Sorry, if I had more information I could give you the nursing care plan. At the moment she sounds like full nursing care which should tell you of the nursing care required.

Answer 3

There are several nursing diagnosis here but the most obvious is:

Impaired mobility related to on going effects of CVA as evidence by vertigo, intolerance to standing and sitting and diplopia.

Begin mobility protocol.
Patient will sit in a chair for all meals.
Patient will stand for all grooming ADL's

Answer 4

If you are in nursing school I'm sure you have a text book that covers this. If not you need a nursing care plan text. By the way we don't use nursing care plans in the real world anymore but they still teach it in school. We use clinical practice guidlines.

Try "Trauma/Injury, Risk" and "Self-care Deficit."

If available in your area, suggest that the doc refer her to a balance clinic.

Answer 5

It really is going to depend on your assessment & what symptoms your patient is having from any "Alteration in Cognitive Function/ Thought Process" which would be my guess for a patient with a CVA. That would be your Nursing Diagnosis.Problems could be "Confusion, impaired memory, agitation, or restlessness" related to " cerebral hypoxia, disease process, or neurological disorder" With Goal it could be " Pt. will function at maximal potential" or "PCP or Pt. will understand disease process" Intervention will depend on what is appropriate like "RN,SW, SP will assess cognitive function/ thought process", like "assess for causes, plan treatment include Pt., PCP, HHA,Vol. in care plan." or "establish regular routines", or "allow time for communication & performance of activities" or "repeat instructions as necessary using clear simple language" or " use of medication as ordered" or "leave night light on to facilitate orientation to place" or"monitor vital signs" in case CVA related to HTN. You need to further individualize your Care Plan depending on what side effects your patient has from the CVA. You might have paralysis, HTN, swallowing problems, confusion (as noted) or pain (comfort) which all patients should have addressed in a Care Plan. Good luck.

Answer 6

middle or inner ear infection. The fluid has caused the disequilibrium. Doesn't sound like CVA to me.