Subjective
Data: Past
health
history,
medications,
symptoms
Objective Data:
General,
respiratory,
cardiovascular,
Gastro-intestinal,
Urinary,
Neruological,
Diagnostic
Test
Secondary
Assessment
Comprehensive
Neurological Exam -
Level of
consciousness
-cognition -motor
abilities -cranial
nerve function
-sensation
-proprioception
-cerebellar function
-deep tendon
reflexes
Planning
Patient, Nurse &
Family Establish Goals:
Maintain stable/improved LOC,
attain maximum physical
functioning, attain maximum
self-care abilities and skills,
maintain stable body functions,
maximize communication
abilities, maintain adequate
nutrition, avoid complications of
stroke, maintain effective
personal and family coping
skills
Implementation
Health Promotion & Acute Intervention & Ambulatory & Home Care
Clinical Manifestations
Motor Function
Communication:
aphasia &
dysarthria
Mood and Affect
exaggerated or
unpredictable
emotional responses,
frustration and/or
depression