Client Presentation
Transcript: What is the importance of an optimistic approach when dealing with a patient who suffered a stroke? CVA Decreased muscle strength and control Decreased endurance Limited range of motion Uncoordinated or jerky movements Nursing Diagnosis 2 Impaired Skin Integrity 4 Nursing Diagnosis 4 Bathing/Hygiene Self-care Deficit 2 Nursing Goal: Acknowledging factors that lead to the low self-esteem feelings When a cerebrovascular accident or stoke occurs the blood flow is temporarily restricted and does not allow the brain cells to receive the nutrients they need, as a result within minutes they begin to die. When a person suffers a stroke is it the opposite side of the brain that is affected and in turn the opposite side of the body. Ischemic stroke is one of the two kinds of cerebrovascular accident, it is caused when a blood clot blocks or plus one of the vessels in the brain. Name: R.R Age: 81 Allergies: NKA Hx: CVA, Chronic renal failure, hyperlipidemia, anemia,ischemic heart disease, prostate enlargement, coronary artery disease, degenerative c-spine. Married, 3 Children, 1 Grandchild, Retired Nimbus Owner Priority: A B C Client was hospitalized on May 12th, 2011 for chest pains. On May 13th he went for stinting of vessels resulting in a failed attempt. He had a pacemaker put in on May 17th due to second degree heart block. On May 19th a second trail was successful on inserting vessel stinting. Post procedure he developed hemiparesis with slurring of speech and flattening of left face. He was admitted to Wascana Rehab on July 7th, 2011 because of the cerebral vascular accident. How is the clients self-esteem threatened by this illness? Loss of independent functioning Social role chances Decreased Control over environment Nursing Goal: Encourage client to be optimistic Critical Thinking Questions: 5 Nursing Goal: Client will understand risk factors Nursing Diagnosis 6 Risk for Infection Client presentation Nursing Diagnose 1 Impaired Physical Mobility Physical Immobilization Body Moisture Scratches skin Extremes of age Shearing forces Pressure How would you be able to cope with loss of functioning of one side of your body and not being able to do previous activities? Nursing Goal: Encourage client to wash with washcloth daily Nursing Diagnosis 3 Moderate Powerlessness Ashly Laliberty Doubts regarding role behavior Dependency Loss of privacy Debilitating conditions Frustration over inability to preform previous tasks Nursing Goal: Client will be moved Q2H on my shift Broken skin on elbow Indwelling catheter Extremes of age Weakness, Fatigue Neuromuscular impairment Unable to do any bathing Nursing Diagnosis 5 Risk for Situational Low Self-esteem Nursing Goal: Client will engage in exercises by end of shift 29/11/12 Path of Physiology