cerebrovascular accident (CVA)
ineffective cerebral Tissue Perfusion may be related to interruption of blood flow (occlusive disorder, hemorrhage, cerebral vasospasm/edema), possibly evidenced by altered level of consciousness, changes in vital signs, changes in motor/sensory responses, restlessness, memory loss; sensory, language, intellectual, and emotional deficits.
impaired physical Mobility may be related to neuromuscular involvement (weakness, paresthesia, flaccid/hypotonic paralysis, spastic paralysis), perceptual/cognitive impairment, possibly evidenced by inability to purposefully move involved body parts/limited range of motion; impaired coordination and/or decreased muscle strength/control.
impaired verbal [and/or written] Communication may be related to impaired cerebral circulation, neuromuscular impairment, loss of facial/oral muscle tone and control; generalized weakness/fatigue, possibly evidenced by impaired articulation, does not/cannot speak (dysarthria); inability to modulate speech, find and/or name words, identify objects, and/or inability to comprehend written/spoken language; inability to produce written communication.
Self-Care Deficit [specify] may be related to neuromuscular impairment, decreased strength/endurance, loss of muscle control/coordination, perceptual/cognitive impairment, pain/discomfort, and depression, possibly evidenced by stated/observed inability to perform ADLs, requests for assistance, disheveled appearance, and incontinence.
risk for impaired Swallowing: risk factors may include muscle paralysis and perceptual impairment.
risk for unilateral Neglect: risk factors may include sensory loss of part of visual field with perceptual loss of corresponding body segment.
impaired Home Maintenance may be related to condition of individual family member, insufficient finances/family organization or planning, unfamiliarity with resources, and inadequate support systems, possibly evidenced by members expressing difficulty in managing home in a comfortable manner/requesting assistance with home maintenance, disorderly surroundings, and overtaxed family members.
situational low Self-Esteem/disturbed Body Image/ineffective Role performance may be related to biophysical, psychosocial, and cognitive/perceptual changes, possibly evidenced by actual change in structure and/or function, change in usual patterns of responsibility/physical capacity to resume role; and verbal/nonverbal response to actual or perceived change.
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