Nursing Care Plan Cva

29.

Nursing Care Plan

(Impaired Verbal Communication) Cues Subjective: “Nahihirapan siyang magsalita, kung minsan umuungol din siya, as verbalized by Mr. D’s wife.”

Objective: Received pt. on lying position on bed, unconscious , with ongoing PNSS 1L regulated @ 1015 gtts./min. (KVO) 200 ml. level infusing well @ left hand. ➢ (+) difficulty in speaking ➢ (+) weakness ➢ (+) headache

Nursing Diagnosis

Scientific Explanation

Impaired verbal communication related to impaired cerebral circulation possibly evidence by impaired articulation.

Difficulty in speaking function resulting from injury of the brain centers. It may involve impairment of ability to read and write as well as to speak, comprehend and understand gestures bec. of the damage of the left hemisphere of the brain is affected and where the Broca’s area located (principal speech center).

Objective/ Planning

Implementation

Rationale

Expected Outcome

Plan: After the provision Establish rapport. of nursing care, the significant others will verbalize understanding about the disease. Monitor and record V/S. Short Term:

To build trusting relationship.

To have baseline data.

After 3 hrs. of N.I the client will establish methods of communication in which needs can be expressed.

Maintain eye contact communication.

Establish good relationship, listening carefully and attending to client’s verbal and non-verbal expressions.

To maintain good communication skills with the patient.

Short Term:

After 3 hrs. of N.I the client shall be able to improved communication abilities and improved family copping.

➢ (+) dizziness ➢ (+) blurred vision ➢ (+)Paralysis on right part of the body ➢ With NGT inserted ➢ With Foley catheter inserted Vital Signs: BP: 140/100 mmHg

Keep communication simple, using all modes of accessing information, visual auditory and kinesthetic. Validate the meaning of nonverbal communication. Be honest if you don’t understand, seek assistance from others. Plan for alternative method of communication incorporated information about type of disability present.

Reinforce that loss of speech does not imply that loss of intelligence.

Assist the pt.’s need to establish means of communicating.

Making assumption to the word maybe wrong.

Using aids in communicating promote learning and recovery.

To limit self-pity and depression.

To give right

Provide sufficient time for client to respond. Use confrontation skills, when appropriate, within an establish nurse-client relationship.

manner when communicating. To clarify discrepancies between verbal and non-verbal cues.

Long Term: Long Term: After 3 days of N.I the client will be able to participate in therapeutic communication. Maintain good environment.

Enhance participation and communication plan.

Provide environmental stimuli as needed or educe stimuli.

Involve SO/ family in plan of care as much as possible.

To maintain contact with reality and to lessen the anxiety that may worsen the problem. To help the pt. recover from his condition and limit deterioration.

To help the pt. in

After 3 days of N.I the pt. shall be able to indicate an understanding of the communication difficulty and plans for ways of handling.

Recommend a tape recorder with pre-recorded emergency massage near the telephone. Information may include name, address, telephone number and type of airway. Refer to appropriate resources (speech therapies).

Maintain adequate rest.

Medication compliance on time.

Promote rest can improve muscular strength.

Administer medications on time.

immediate emergency assistance.

Speech therapies can help the patient to cope from his condition. To stimulate the muscle to function well.

Sometimes, medications are given to stimulate the brain to function well.