CUES AND CLUES DIAGNOSIS ANALYSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Left side completely paralyzed – stoke patient since 2007

Limited range of motion

(+) Stiffening of left elbow joint, wrist and digital bones

(+) Edema on left hand

(+) stiffening on left foot

(+) foot drop

Impaired physical mobility related to decreased motor function of extremities hand secondary to damage to upper motor neurons

An upper motor neuron impairment in a hemisphere of the brain results in loss of voluntary control over motor movements of the body which may result to decrease I its function and/or paralysis.

After 2 weeks of nursing intervention, client will be able to:

a. Demonstrate technique /behaviors that enable resumption of activities

b. Maintain or increase strength and function of affected and/or compensatory body part

c. Improve mobility and maintain strength of unaffected body part

After 1 month of nursing intervention, client will be able to:

a. Maintain position and function of skin integrity as evidence from improvement of bed sore and contractures, foot drop

Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 0-4 scale.

Change positions at least every 2 hours (supine, side lying) and possibly more often if placed on affected side.

Prop extremities in functional position; use footboard during period of flaccid paralysis. Maintain neutral position of head

Observe affected side for color, edema, or other signs of compromised circulation

Provide warm compress on edematous hand and elevate with pillow

Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids and support such as sheepskin pads, pillows, rolls, foot supports, air mattress, water bed, etc. as necessary

Begin active/ passive range- of- motion exercises to all the extremities (including splinted) on admission. Encourage exercises such as quadriceps/ gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet.

Provide massage except on edematous part, elevate head and place on sitting

Identifies strengths/ deficiencies and may provide information regarding recovery. Assists in choice of interventions because different techniques are used for flaccid and spastic types of paralysis.

Reduces risk of tissue ischemia/ injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/ decubitus ulcer.

Prevents contractures/ footdrop and facilitates use when/if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.

Edematous tissue is more easily traumatized and heals more slowly.

To facilitate circulation and comfort

Pressure points over bony prominences are most at risk for decreased perfusion/ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus ulcer development.

Minimizes muscle atrophy, promotes circulation and helps prevent contractures.

Helps stabilize BP (restores vasomotor tone), promotes maintenance of extremities in a

After 2 weeks of nursing intervention, client was able to:

a. Demonstrate technique /behaviors that enable resumption of activities

b. Maintain or increase strength and function of affected and/or compensatory body part

c. Improve mobility and maintain strength of unaffected body part

After 1 month of nursing intervention, client was able to:

a. Maintain position and function of skin integrity as evidence from improvement of bed sore and contractures, foot drop

position

Provide immobilization as needed to affected side

Assist to develop sitting balance (e.g. raise head of bed; assist to sit on edge of bed) and standing balance (e.g. put flat walking shoes on client, support client’s lower back with hands while positioning own knees outside client’s knees)

Maintain body alignment in functional position

Pad chair seat with foam or water-filled cushion, and assist client to shift weight at frequent intervals.

Set goals with client/ SO for increasing participation in activities/ exercise and position changes.

Encourage client to assist with movement and exercises using unaffected extremity to support/ move weaker side

Collaborative:

Provide egg-crate mattress, water bed, flotation device or specialized bed (e.g. kinetic) as indicated.

Consult with physical therapist regarding active, resistive exercises and client

functional position and emptying of bladder/kidneys, reducing risk of urinary stones and infections from stasis, promotes blood circulation

Aids in retraining neuronal pathways, enhancing proprioception and motor response

Helps prevent/lessen contractures

Prevents/ reduces pressure on the coccyx/ skin breakdown.

Promotes sense of expectation of progress/ improvement, and provides some sense of control/ independence.

May respond as if affected side is no longer part of body and needs encouragement and active training to “reincorporate” it as part of own body

Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown/ decubitus ulcer formation. Specialized beds help with positioning, enhance circulation and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia

Individualized program can be developed to meet particular needs/ deal with deficits in

ambulation

Assist with electrical stimulation,e.g. transcutaneous electrical nerve stimulator (TENS) unit, as indicated

balance, coordination, strength

May assist with muscle strengthening and increase voluntary muscle control, as well as pain control.

CUES AND CLUES DIAGNOSIS ANALYSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Unable to speak and express self

Inability to form words

Dyspnea

Pleading eyes

Gestures – hand movements

Hostility

Facial asymmetry

Impaired communication related to the effects of hemisphere (right) damage on language or speech

Language and communication may be affected by stroke. There may be damage to Wernicke’s speech area, causing receptive aphasia or Broca’s speech areas causing expressive aphasia.Stroke is the most common cause of aphasia (loss of speech)

Within 2 hours of nursing intervention, the client will:

a. Indicate an understanding of the communication problems

b. Express signs of decreasing stress due to inability to relay needs and symptoms

After 1 week of intervention, the patient will be able to:

a. Establish method of communication in which needs can be expressed

b. Use resources appropriately

c. Express improvement in communication with health providers and relatives

Assess type/ degree of dysfunction: e.g. receptive aphasia, client does not seem to understand words or has trouble speaking or making self understood, expressive aphasia

Differentiate aphasia from dysarthria

Ask client to follow simple commands (e.g. “shut your eyes”)

Post notice at nurses’ station and client’s room about speech impairment. Provide special call bell if necessary

Reduce environmental noise that can interfere with comprehension

Provide alternative methods of communication: e.g., writing or felt board, pictures. Provide visual clues (gestures, pictures, “needs” list, demonstration)

Anticipate and provide for client’s needs

Talk directly to client, speaking slowly and

Helps determine area and degree of brain involvement and difficult client has with any or all steps of the communication process. Client may have trouble understanding spoken words, speaking words correctly or may experience damage to both areas.

Choice of interventions depends on type of impairment. Aphasia is defect in using and interpreting symbols of language and may involve sensory and/ or motor components. A dysarthic person can understand, read and write language but has difficulty forming/ pronouncing words because of weakness and paralysis of oral musculature, resulting in softly spoken speech

Tests for receptive aphasia.

Allays anxiety related to inability to communicate and fear that needs will not be met promptly. Call bell that is activated by minimal pressure is useful when client is unable to use regular call system.

To facilitate understanding

Provides for communication of needs/ desires based on individual situation/ underlying deficit.

Helpful in decreasing frustration when dependent on others and unable to communicate desires

Reduces confusion/ anxiety at having to process and respond to large amount of information at

Within 2 hours of nursing intervention, the client was able to:

a. Indicate an understanding of the communication problems

b. Express signs of decreasing stress due to inability to relay needs and symptoms

After 1 week of intervention, the patient was able to:

A. Establish method of communication in which needs can be expressed

B. Use resources appropriately

C. Express improvement in communication with health providers and relatives

distinctly. Use yes/ no questions to begin with, progressing in complexity as client responds; Use all means of communication possible, visual, auditory and kinesthetic.

Speak with normal volume and avoid talking too fast. Give client ample time to respond. Talk without pressing for a response

Validate meaning of nonverbal communication; do not make assumptions; be honest if you do not understand, seek assistance with relative and other health providers

Encourage SO/ visitors to persist in efforts to communicate with client; e.g., reading mail, discussing family happenings even if client is unable to respond appropriately

Discuss familiar topics; e.g. job, family, hobbies

Respect clients’ preinjury capabilite; avoid “speaking down” to client or making patronizing remarks

Collaborative:

Consult with/ refer to speech therapist

one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word/ idea association.

Client is not necessarily hearing impaired, and raising voice may irritate or anger client. Forcing responses can result in frustration and may cause client to resort to “automatic” speech e.g. garbled speech, obscenities.

For error to be avoided

It is important for family members to continue talking to client to reduce client’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family.

Promotes meaningful conversation and provides opportunity to practice skills.

Enables client to feel esteemed because intellectual abilities often remain intact.

Assesses individual verbal capabilities and sensor, motor and cognitive functioning to identify deficits/ therapy needs.