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Left side Impaired An upper motor After 2 weeks of nursing Assess functional ability/extent of Identifies strengths/ deficiencies and may After 2 weeks of nursing
completely physical mobility neuron intervention, client will be impairment initially and on a regular provide information regarding recovery. Assists intervention, client was
paralyzed ʹ related to impairment in a able to: basis. Classify according to 0-4 scale. in choice of interventions because different able to:
stoke patient decreased motor hemisphere of techniques are used for flaccid and spastic types
since 2007 function of the brain results a. pemonstrate technique of paralysis. a. pemonstrate
extremities hand in loss of /behaviors that enable technique /behaviors
Limited range secondary to voluntary control resumption of activities Change positions at least every 2 hours Reduces risk of tissue ischemia/ injury. Affected that enable resumption
of motion damage to upper over motor (supine, side lying) and possibly more side has poorer circulation and reduced of activities
motor neurons movements of b. Maintain or increase often if placed on affected side. sensation and is more predisposed to skin
(+) Stiffening the body which strength and function breakdown/ decubitus ulcer. b. Maintain or increase
of left elbow may result to of affected and/or strength and function
joint, wrist and decrease I its compensatory body Prop extremities in functional position; Prevents contractures/ footdrop and facilitates of affected and/or
function and/or part use footboard during period of flaccid use when/if function returns. Flaccid paralysis compensatory body
digital bones
paralysis. paralysis. Maintain neutral position of may interfere with ability to support head, part
c. Improve mobility and head whereas spastic paralysis may lead to deviation
(+) Edema on maintain strength of of head to one side. c. Improve mobility and
left hand unaffected body part maintain strength of
Observe affected side for color, edema, Edematous tissue is more easily traumatized unaffected body part
(+) stiffening After 1 month of nursing or other signs of compromised and heals more slowly.
intervention, client will be circulation After 1 month of nursing
on left foot
able to: intervention, client was
Provide warm compress on edematous To facilitate circulation and comfort able to:
(+) foot drop a. Maintain position and hand and elevate with pillow
function of skin a. Maintain position and
integrity as evidence Inspect skin regularly, particularly over Pressure points over bony prominences are function of skin
from improvement of bony prominences. Gently massage any most at risk for decreased perfusion/ischemia. integrity as evidence
bed sore and reddened areas and provide aids and Circulatory stimulation and padding help from improvement of
contractures, foot drop support such as sheepskin pads, pillows, prevent skin breakdown and decubitus ulcer bed sore and
rolls, foot supports, air mattress, water development. contractures, foot
bed, etc. as necessary drop

Begin active/ passive range- of- motion


exercises to all the extremities (including Minimizes muscle atrophy, promotes circulation
splinted) on admission. Encourage and helps prevent contractures.
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 Helps stabilize BP (restores vasomotor tone),
promotes maintenance of extremities in a
position functional position and emptying of
bladder/kidneys, reducing risk of urinary stones
and infections from stasis, promotes blood
circulation

Provide immobilization as needed to Aids in retraining neuronal pathways, enhancing


affected side proprioception and motor response

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 client͛s
lower back with hands while positioning
own knees outside client͛s knees)

Maintain body alignment in functional Helps prevent/lessen contractures


position

Pad chair seat with foam or water-filled Prevents/ reduces pressure on the coccyx/ skin
cushion, and assist client to shift weight breakdown.
at frequent intervals.

Set goals with client/ SO for increasing Promotes sense of expectation of progress/
participation in activities/ exercise and improvement, and provides some sense of
position changes. control/ independence.

Encourage client to assist with May respond as if affected side is no longer part
movement and exercises using of body and needs encouragement and active
unaffected extremity to support/ move training to ͞reincorporate͟ it as part of own
weaker side body

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Provide egg-crate mattress, water bed,


Promotes even weight distribution, decreasing
flotation device or specialized bed (e.g.
pressure on bony points and helping to prevent
kinetic) as indicated.
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
Consult with physical therapist regarding
Individualized program can be developed to
active, resistive exercises and client
meet particular needs/ deal with deficits in
ambulation
balance, coordination, strength

Assist with electrical stimulation,e.g. May assist with muscle strengthening and
transcutaneous electrical nerve increase voluntary muscle control, as well as
stimulator (TENS) unit, as indicated pain control.
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Unable to Impaired Language and  ! " Assess type/ degree of dysfunction: e.g. Helps determine area and degree of brain  ! "
speak and communication communication #$ receptive aphasia, client does not seem to involvement and difficult client has with any or #$% 
express self related to the may be affected % understand words or has trouble speaking all steps of the communication process. Client 
effects of by stroke. There or making self understood, expressive may have trouble understanding spoken words,
Inability to hemisphere may be damage a. Indicate an aphasia speaking words correctly or may experience a. Indicate an
form words (right) damage to Wernicke͛s understanding of the damage to both areas. understanding of the
on language or speech communication communication
pyspnea speech area, causing problems pifferentiate aphasia from dysarthria Choice of interventions depends on type of problems
receptive impairment. Aphasia is defect in using and
Pleading eyes aphasia or b. Express signs of interpreting symbols of language and may b. Express signs of
Broca͛s speech decreasing stress due involve sensory and/ or motor components. A decreasing stress due
Gestures ʹ areas causing to inability to relay dysarthic person can understand, read and to inability to relay
hand expressive needs and symptoms write language but has difficulty forming/ needs and symptoms
movements aphasia. pronouncing words because of weakness and
Stroke is the !&%'! paralysis of oral musculature, resulting in softly !&%'!
Hostility most common #( spoken speech #(
cause of aphasia % % 
Facial (loss of speech) Ask client to follow simple commands (e.g. Tests for receptive aphasia.
asymmetry a. Establish method of ͞shut your eyes͟) A. Establish method of
communication in communication in
which needs can be Post notice at nurses͛ station and client͛s Allays anxiety related to inability to which needs can be
expressed room about speech impairment. Provide communicate and fear that needs will not be expressed
special call bell if necessary met promptly. Call bell that is activated by
b. Use resources minimal pressure is useful when client is unable B. Use resources
appropriately to use regular call system. appropriately

c. Express improvement Reduce environmental noise that can To facilitate understanding C. Express improvement
in communication interfere with comprehension in communication with
with health providers health providers and
and relatives Provide alternative methods of Provides for communication of needs/ desires relatives
communication: e.g., writing or felt board, based on individual situation/ underlying
pictures. Provide visual clues (gestures, deficit.
pictures, ͞needs͟ list, demonstration)

Anticipate and provide for client͛s needs Helpful in decreasing frustration when
dependent on others and unable to
communicate desires

Talk directly to client, speaking slowly and Reduces confusion/ anxiety at having to process
distinctly. Use yes/ no questions to begin and respond to large amount of information at
with, progressing in complexity as client one time. As retraining progresses, advancing
responds; Use all means of communication complexity of communication stimulates
possible, visual, auditory and kinesthetic. memory and further enhances word/ idea
association.

Speak with normal volume and avoid Client is not necessarily hearing impaired, and
talking too fast. Give client ample time to raising voice may irritate or anger client. Forcing
respond. Talk without pressing for a responses can result in frustration and may
response cause client to resort to ͞automatic͟ speech e.g.
garbled speech, obscenities.

Validate meaning of nonverbal For error to be avoided


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 It is important for family members to continue
to communicate with client; e.g., reading talking to client to reduce client͛s isolation,
mail, discussing family happenings even if promote establishment of effective
client is unable to respond appropriately communication, and maintain sense of
connectedness with family.

piscuss familiar topics; e.g. job, family, Promotes meaningful conversation and
hobbies provides opportunity to practice skills.

Respect clients͛ preinjury capabilite; avoid Enables client to feel esteemed because
͞speaking down͟ to client or making intellectual abilities often remain intact.
patronizing remarks

Collaborative:
Assesses individual verbal capabilities and
Consult with/ refer to speech therapist sensor, motor and cognitive functioning to
identify deficits/ therapy needs.