Questions and Answers
What are the expected outcomes for a nursing diagnosis of Ineffective Cerebral Tissue Perfusion?
What is one intervention a nurse can provide for Ineffective Cerebral Tissue Perfusion?
Monitor neurologic status at least every 30 minutes initially and then every 4 hours or prn.
What is the expected outcome for a patient with Ineffective Airway Clearance?
The expected outcome for a patient with the nursing diagnosis Risk for Injury is to remain free from injury.
Signup and view all the answers
What intervention can help a patient with Impaired Physical Mobility?
Signup and view all the answers
The expected outcome for a patient with Imbalanced Nutrition, less than body requirements is to maintain adequate nutrition without ______.
Signup and view all the answers
The nursing diagnosis Risk for Impaired Skin Integrity is related to immobility and incontinence.
Signup and view all the answers
What is one intervention for a patient at Risk for Falls?
Signup and view all the answers
What is one of the objectives for a patient with a self-care deficit?
Signup and view all the answers
What is the expected outcome for a patient with Acute or Chronic Confusion?
Signup and view all the answers
Study Notes
Nursing Diagnoses and Expected Outcomes
-
Ineffective Cerebral Tissue Perfusion
- Related to interruption, outcomes include reduced dizziness, improved level of consciousness (LOC), and improved motor/sensory function.
-
Ineffective Airway Clearance
- Linked to decreased mobility and poor cough effort, with goals to maintain an open airway and normalized respiratory rates.
-
Risk for Injury
- Associated with seizures or thrombolytic therapy, with an aim to keep the patient injury-free through constant monitoring and implementing safety measures.
-
Impaired Physical Mobility
- Resulting from decreased motor function, expected outcomes include maintaining body alignment and engaging in rehabilitation exercises.
-
Imbalanced Nutrition
- Due to swallowing difficulties, patients should maintain nutrition without aspiration, monitored by screening for dysphagia and ensuring proper dining procedures.
-
Risk for Impaired Skin Integrity
- Related to immobility and incontinence, goals involve maintaining skin integrity through regular assessments and repositioning.
-
Risk for Falls
- Due to mobility and sensory changes, prevention strategies include safety assessments and ensuring patient items are within reach.
-
Self-Care Deficit
- Related to motor function impairments, focus on encouraging independence and assisting with daily living activities.
-
Acute or Chronic Confusion
- Resulting from cerebral ischemia, expected outcomes aim for clear thought processes and patient safety.
Interventions
-
Monitor Neurological Status
- Check every 30 minutes initially, transitioning to every 4 hours as stable.
-
Vital Signs Monitoring
- Assess every 30 minutes initially, then every 4 hours.
-
Oxygen Saturation Management
- Administer oxygen if SpO2 is below 92%.
-
Blood Glucose Monitoring
- Report levels exceeding 140 mg/dL.
-
Airway Management
- Monitor lung sounds, encourage deep breathing, and apply suction if necessary.
-
Preventing Falls
- Implement call light availability and patient education about requesting assistance.
-
Nutritional Safety
- Keep patient NPO until swallowing is evaluated and have suction equipment on hand during meals.
-
Skin Integrity Preservation
- Conduct frequent skin assessments and perform positioning every 2 hours.
Education and Support
-
Encourage Independence
- Assist patients in using the non-dominant side to enhance self-care abilities.
-
Provide Reassurance
- Maintain a calm environment, reducing anxiety related to confusion and assessing for safety concerns.
-
Engagement in Therapy
- Work with physical and occupational therapists to promote recovery of motor functions.
Safety Measures
-
Implement Seizure Precautions
- Monitor for signs of hemorrhage post-thrombolytic therapy.
-
Suction Equipment Availability
- Ensure suction devices are ready for patients with potential aspiration risks.
-
Educate Family and Patient
- Inform about fall risks and encourage proactive communication for support.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
This quiz focuses on nursing care plans specific to patients who have suffered a stroke. Explore various nursing diagnoses, expected outcomes, and interventions related to ineffective cerebral tissue perfusion. Enhance your understanding and practical application of nursing concepts in stroke care.
