6994992
Beschreibung
Mindmap von Kimberly Legaspi, aktualisiert more than 1 year ago
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Erstellt von Kimberly Legaspi
vor etwa 8 Jahre
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|
60-YEAR OLD CLIENT WITH
RIGHT-SIDED PARALYSIS DUE
TO STROKE
- IMMOBILITY
- Cardiovascular/Neurovascular
System
- Increased workload on heart
- Postural hypotension
- Deep vein thrombosis in legs
- Compression
stockings
- Elevate legs
- Pillows underneath valves and
heels of feet hanging over
- Neurovascular
assessment
- Compression
stockings
- Deep vein thrombosis in lungs
- Edema
- Increased workload on heart
- Respiratory System
- Chest muscles weakened
- Chest muscles weakened
- Integumentary
System
- Skin breakdown
- Pressure ulcers
- Reposition client
- Apply moisturizer and barrier creams
- Adequate hydration: 2L/day
- Reposition client
- Integumentary
Assessment
- Pressure ulcers
- Skin breakdown
- Musculoskeletal System
- Muscle atrophy
- Muscle reconditioning
- Increased hospital stay
- Consult physiotherapist and occupational therapist
- Increased hospital stay
- Increased risk of falls or injuries
- Morse Fall Scale
Assessment
- Morse Fall Scale
Assessment
- Musculoskeletal
Assessment + ROM
Exercises
- Muscle reconditioning
- Muscle atrophy
- Nutritional
Status
- Risk for aspiration
- NPO Status
- Assess hydration of oral mucous
membranes
- Frequent oral care
- Frequent oral care
- Assess hydration of oral mucous
membranes
- Nasogastric tube
- Position client in high Fowler's
- NPO Status
- Low salt and cholesterol diet
- Risk for aspiration
- Gastrointestinal
System
- Decreased perisalsis
- Risk for constipation
- Valsalva maneuver during bowel
movements
- Nausea and vomiting
- Quiet environment
- Minimize odours
- Minimize client and nurse movement
- Quiet environment
- Valsalva maneuver during bowel
movements
- Risk for constipation
- Decreased perisalsis
- Cardiovascular/Neurovascular
System
- PSYCHOLOGICAL/MENTAL HEALTH
- Altered self-esteem and body image
- Depression and anxiety due to lifestyle modification
- Altered self-esteem and body image
- QUALITY OF LIFE
- Age
- Life experiences
- Life experiences
- Family and friend support
- Values, beliefs, religion
- Material/technology-focused
vs. basic needs and family
- Material/technology-focused
vs. basic needs and family
- Social determinants of
health
- Income
- Availability of food
- Availability of food
- Housing
- Employment conditions
- Social justice
- Healthy child development
- Education
- Health literacy
- Health literacy
- Social justice
- Income
- Age
- LIFESTYLE MANAGEMENT
- Medication administration
and adherence
- Walker or wheelchair use
- Medication administration
and adherence
- NURSE-CLIENT RELATIONSHIP
- Trust , respect, empathy
- Open discussion of goals
- Strengths-based nursing
- Discover client's strengths
- Discover client's strengths
- Trust , respect, empathy
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