Client’s Diagnosis: Hemorrhagic Stroke (CVA)

Nursing Diagnosis: Impaired Verbal Communication

Assessment Diagnosis Scientific Planning Interventions Rationale Evaluation

Explanation
Subjective: “Nung Impaired Verbal A Cardiovascular Long term: Independent Independent Goal met as evidenced
kinakausap ko siya Communication related Disease (CVD), After 3 days of nursing by:
nahihirapan siyang to loss of facial muscle which may be caused interventions, the client 1. Monitor vital signs1. Establishes baseline
magsalita.” as tone or control as by hemorrhage, will be able to utilize a with emphasis to BP. data for review of -The client will have
verbalized by the sister evidenced by thrombus, embolism form or method of existing conditions. utilized a form or
of the client. expressive aphasia and or vasospasm, can communication in 2. The nurse should set method of
right-sided facial result in a local area which needs can be 2. Learn patient needs aside enough time to communication in
Objective: droop. of cell death, called expressed and to relate and pay attention to attend to all of the which needs can be
-Expressive aphasia infarct. It is caused effectively with nonverbal cues. details of patient care. expressed and to relate
-Right-sided facial by a lack of blood persons and her Care measures may effectively with persons
droop supply which is then environment such as take longer to complete and her environment
-Right-sided surrounded by an using paper and pen or in the presence of a such as using paper and
hemiparesis area of cells that are flash cards. communication deficit. pen or flash cards.
-History of CVA with secondarily affected. 3. Impaired ability to -The client and
right-sided paralysis Since symptoms Short term: communicate significant other shall
-GCS is E3, V3, M4 = depend on the After 4 hours of 3. Provide an spontaneously is have verbalized
10/15 location of the stroke nursing interventions, atmosphere frustrating and understanding of health
and size of the the client and of acceptance and embarrassing. Nursing teachings given.
infarct, it could significant other will privacy through actions should focus on
involve the brain’s be able to verbalize speaking slowly and in a decreasing the tension
Brocca’s area, which understanding of health normal tone, not forcing and conveying an
is primary teachings given. the client to understanding of how
responsible communicate. difficult the situation
for communication must be for the client.
through facial 4. Deliberate actions
expressions and can be taken to improve
speech. By causing speech. As the client’s
damage to this area, speech improves, his
the patient’s 4. Instruct techniques to confidence will
communicating skills the client to improve increase and she will
are greatly altered speech by initially make more attempts at
and affected asking questions that speaking.
(Brunner et al., client can answer with a 5. To help the client
2000). “yes” or “no”. and nurse communicate
 easily.
5. Instruct to use eye
blinks or finger 6. Simple, one-action
movements for “yes” or directions enhance
“no” responses. comprehension for the
6. Provide concrete patient with language
directions that the impairment.
patient is physically
capable of doing such as 7. Improving the
“point to the pain,” client’s comprehension
“open your mouth,” can help to decrease
“turn your head”. frustration and increase
7. Utilize strategies to trust. Clients with
improve the client’s aphasia can correctly
comprehension by using interpret tone of voice.
touch and behavior to
communicate calmness
and adding other non –
verbal methods
of communication such
as pointing or using
flash cards for basic
needs; using 8. To maximize
pantomime; or using patient’s sense of
paper and pen. independence.
8. Place important 9. Practice will increase
objects within reach. the patient’s
communication.
9. Provide practice 10. Enhances
sessions within the day. participation and
10. Involve the commitment to plan.
significant others in the 11. Imparts thought and
plan of care. answers the needs of
11. Educate relatives to the client with lessened
establish a method difficulty.
of communication 12. Fatigue can make
through sign language. communication
12. Provide adequate difficult or impossible.
time to rest. Dependent
13. To promote
 Dependent recovery.
13. Administer and 14. To decrease blood
regulate IVF as ordered. pressure.
14. Administer anti-
hypertensive medication Interdependent
as ordered. 15. Specialized services
may be required to
Interdependent meet needs.
15. Refer to appropriate
resources such as speech
therapist, group therapy,
individual/family and/or
psychiatric counseling.
Reference:
Brunner, L. S., Smeltzer, S. C., Suddarth, D. S., Smeltzer, S. C., & Bare, B. G. (2000). Brunner and Suddarth's textbook of medical-surgical nursing (9th ed.). Lippincott Raven.