Date/ Time J U L Y

Cues

Need

Nursing Diagnosis

Goal of Care

Nursing Intervention

Evaluation

OBJECTIVE:

H E

Risk for injury r/t right sided body weakness secondary to CVA

After 2 hrs of nursing intervention, the patient will be able to identify and apply methods to promote safety such as:

1.) Perform thorough assessment regarding safety issues when planning for

July , 2011 @ 9pm 7-3 shift

right sided body weakness

A L T H

Goal Met

, 2 0 1 1

Rationale: P E R C E
A cerebrovascular accident, also known as a CVA or stroke, is a blood clot or ruptured artery that causes damage to some part of the brain by interrupting blood flow and oxygen. The area of the brain damaged dictates what kind of disability will result

After 2 hours of nursing care, patient was able to identify and apply methods to promote safety.

a.) limiting excessive activities b.) Use of assistive devices such as: wheel chair

client care and/or preparing for discharge from care. Failure to accurately assess and intervene or refer these issues can place the client at

P T

a.) Patient was able to limit activities b.) Able to used wheel chair in transferring from one place to

7 am

I O N

and whether the condition is

H E A L T H

temporary or permanent. Even if someone is still able to walk and maintain mobility after a stroke, home modifications may be necessary to prevent

needless risk and creates negligence issues for the healthcare practitioner. 2.) Ascertain knowledge of safety needs/injury prevention and motivation to prevent injury in home, community,

another.

M A N A G E M E N T

falls and injuries. Factors that increased the risk for injury include decrease LOC. Weakness, flaccidity, spasticity, altered thought process, motor, visual, and spatial perceptual impairments. ( Black & Hawk: 2005:2128)

P A T T

and work setting. 3.) Assess mood,

E R N

coping abilities, personality styles (e.g., temperament , aggression, impulsive behaviour, level of selfesteem) That may result in carelessness /increase risk-taking without consideratio n of consequenc es. 4.) Provide healthcare

within a culture of safety (e.g., adherence to nursing standards of care and facility safecare policies) to prevent errors resulting in client injury, promote client safety, and model safety behaviours for client/SO(s): Maintain bed/chair in

lowest position with wheels locked Ensure that pathway to bathroom is unobstructed and properly lighted. Place assistive devices (e.g., walker, cane, glasses, hearing aid) within reach. Instruct client/SO(s) to request assistance as needed; make sure call light is within reach and client knows how to

operate. Monitor environment for potentially unsafe conditions and modify as needed. 5.) Demonstrate / encourage use of techniques to reduce /manage stress and vent emotions, such as anger, hostility. 6.) Discuss importance of selfmonitoring of conditions/

emotions that can contribute to occurrence of injury (e.g., fatigue, anger, irritability)