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Ineffective Cerebral Trauma Case Study

Decent Essays

This is a 71-year-old male pt of Derby health & Rehab with the problem of weakness and CVA. What I learned is if a pt is weak it can impair the ability to maintain activity. My pt is weak secondary to stroke which impaired the ability to maintain activity caused by destruction of motor neurons in the pyramidal pathways. Also I learned that CVA is the leading cause of serious, long term disability. Store occurs when blood supply to the brain is blocked or restricted. Currently the pt left side arm is weak and he is totally dependent now for mobility because of stroke. He is also wearing O2 at 4 liters.
Care Plan Interpretation
Problem 1 CVA Ineffective Cerebral Tissue Perfusion
Therapeutic intervention
Administer oxygen therapy as prescribed daily
Rationale
Oxygen saturation needs to be greater than 90%. Increasing …show more content…

Rationale
Rest between activities provides time for energy conservation and recovery.
Safety intervention
Anticipate the patient’s needs for example keep telephone and tissues within reach every shift.
Rationale
Attention to placement of commonly used supplies can reduce the risk for falling while reaching.
Diagnostic intervention
Assist in assigning priority to activities to accommodate energy levels
Rationale
With a reduced functional capacity, pacing of priority tasks first may better meet the patient’s needs.
Referrals intervention
Refer pt to PT for ROM and strengthening exercises daily.
Rationale
Exercise promotes increased venous return, prevents contractures, and maintains/ increases muscle strength and endurance.

Narrative
0700 Pt in his room awake getting ready for breakfast with the assistance of CNA. No sign of distress noted at this time………………………………...L.Gotora PNS2/WATC
0830 Pt went with Physical Therapy for exercise assisted by PT via wheel chair. Good appetite this morning, Ate 80 % of his breakfast……………………L.Gotora

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