Stroke Nursing Care Plan
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
Date: October 15, 2050
Patient Information:
Patient Name | Age | Gender | Medical Record Number |
|---|
Jasen Gaylord | 68 | Male | 123456789 |
Stroke Nursing Diagnosis:
Impaired Physical Mobility related to hemiparesis on the right side as evidenced by inability to move right arm and leg.
Risk for Aspiration related to difficulty swallowing (dysphagia).
Acute Pain related to muscle stiffness and spasms post-stroke.
Deficient Knowledge regarding stroke recovery and prevention strategies.
Goals and Outcomes:
Goal Number | Goal Description | Expected Outcome | Target Date |
|---|
1 | Improve physical mobility and strength on the right side. | Patient will demonstrate increased range of motion (ROM) in the right arm and leg. | November 15, 2050 |
2 | Prevent aspiration and choking during meals. | Patient will tolerate soft foods without coughing or choking. | November 30, 2050 |
3 | Reduce pain and discomfort caused by muscle stiffness. | Patient will report pain level ≤ 3 on a scale of 1-10. | November 25, 2050 |
4 | Educate patient and family on stroke recovery and prevention. | Patient and family will demonstrate understanding of stroke prevention strategies. | December 5, 2050 |
Nursing Interventions and Rationales:
Impaired Physical Mobility:
Intervention: Assist patient with passive range of motion exercises twice a day.
Rationale: Helps prevent contractures and improve muscle function, promoting better mobility.
Intervention: Encourage patient to perform active range of motion exercises with assistance as tolerated.
Rationale: Promotes muscle strength and joint flexibility, which aids in recovery.
Risk for Aspiration:
Intervention: Position patient upright (90-degree angle) during and after meals.
Rationale: Helps reduce the risk of food or liquid entering the airway and causing aspiration.
Intervention: Consult speech therapist for evaluation and recommendation of modified diet and swallowing techniques.
Rationale: Ensures safe swallowing techniques and appropriate diet to minimize aspiration risk.
Acute Pain:
Intervention: Administer prescribed analgesics as needed, monitor pain levels every 4 hours.
Rationale: Effective pain management reduces discomfort and aids in patient participation in rehabilitation activities.
Intervention: Apply heat or cold packs to affected muscles as tolerated.
Rationale: Heat or cold therapy can reduce muscle spasms and alleviate pain.
Deficient Knowledge:
Intervention: Educate patient and family about stroke, its impact, and recovery process during daily visits.
Rationale: Knowledge empowers the patient and family to engage in recovery efforts and reduce anxiety.
Intervention: Provide written materials on stroke prevention and lifestyle modifications (e.g., diet, exercise, smoking cessation).
Rationale: Helps reinforce teaching and supports long-term stroke prevention.
Evaluation:
Goal Number | Outcome Achieved | Modifications Needed | Date |
|---|
1 | Patient demonstrates improved right arm and leg mobility. | No | November 15, 2050 |
2 | No aspiration incidents during meals. | No | November 30, 2050 |
3 | Pain level decreased to 2/10 after intervention. | Yes | November 25, 2050 |
4 | Patient and family show understanding of stroke prevention. | No | December 5, 2050 |
Notes:
The patient’s stroke recovery will require ongoing adjustments to the care plan as progress is monitored.
Continuous communication between nursing staff, physical therapy, and other healthcare providers is essential for optimal care.
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