Alterations in the Nervous System Nursing Diagnosis / Interventions for the Stroke Patient.
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Transcript of Alterations in the Nervous System Nursing Diagnosis / Interventions for the Stroke Patient.
Alterations in the Nervous Alterations in the Nervous SystemSystem
Nursing Diagnosis / Interventions for the Stroke Patient
Cerebrovascular AccidentCerebrovascular AccidentAssessmentAssessment
Immediate – assess & stabilize◦ ABCs, VS, 12-lead EKG◦ Neurologic screening◦ Oxygen if hypoxic◦ IV access ◦ Check glucose◦ Activate stroke team
Immediate Neuro Assessment Establish symptom onset
◦ Review hx◦ Stroke Scale
Cerebrovascular AccidentCerebrovascular AccidentNursing GoalsNursing Goals
• Maintain stable body functions• Minimize complications of stroke• Maximize communication abilities• Maintain adequate nutrition• Attain maximum physical
functioning• Maintain effective personal & family
coping
Impaired SwallowingImpaired SwallowingInterventions include:
◦Assessment of patient’s ability to swallow
◦Patient positioning to facilitate the process of swallowing before feeding
◦Appropriate diet for the patient, including semisoft foods and fluids
◦Aspiration precautions
Disturbed Sensory Disturbed Sensory PerceptionPerception
Interventions include:◦Right hemisphere damage:
problems with visual-perceptual or spatial-perceptual tasks
-ADLs-Ambulation
◦Left hemispheric damage: problems with memory deficits
and ability to carry out simple tasks
Unilateral NeglectUnilateral Neglect
This syndrome is most commonly seen with right cerebral stroke
Teach patient to:◦Observe safety measures◦Touch and use both sides of the
body◦Use scanning technique ( turn head
from side to side) to expand the visual field
Impaired Physical Mobility Impaired Physical Mobility and Self-Care Deficitand Self-Care DeficitInterventions include:
◦Range-of-motion exercises for the involved extremities
◦Change of patient’s position frequently
◦Prevention of deep vein thrombosis◦Therapy focused on patient
performance of ADLs
Impaired Verbal Impaired Verbal CommunicationCommunication
Language or speech problems r/t damage to the dominant hemisphere
Expressive aphasia (Broca’s area) frontal lobe area
Receptive aphasia (Wernicke’s or
sensory) temporoparietal area
Urinary and Bowel Urinary and Bowel IncontinenceIncontinenceAltered level of consciousness
may cause incontinence or impaired innervation or an inability to communicate
Develop a bladder and bowel training program
Meds: stool softeners
Cerebrovascular AccidentCerebrovascular AccidentAcute PhaseAcute Phase
Assess: Frequently to assess CVA evolutionNeuro : -Glascow Coma Scale (mental status, LOC, pupillary response, extremity movement, strength, sensation) -ICP -Communication—speaking & understanding; sensory-perceptual alterations
CV: -cardiac monitoring (VS, PO,) -hemodynamic monitoring
Cerebrovascular AccidentCerebrovascular AccidentAcute Phase ContinuedAcute Phase Continued
Resp: - assess airway/air exchange -check for aspiration
GI: -swallowing (gag reflex) - bowel sounds, constipation
GU : urinary continenceIntegumentary :
-skin integrity, hygieneCoping :
- individual and family
Cerebrovascular AccidentCerebrovascular AccidentAcute PhaseAcute Phase
Nsg Action:Supportive Care
Respiratory – spans from intubation to breathing on own
Musculoskeletal -- Positioning – side-to-side; HOB elevated; PROM exercise; splints; shoes/footboard
GI – enteral feedings initially GU – foley catheterSkin – preventive careMeds: anti platelet
Cerebrovascular AccidentCerebrovascular AccidentAcute PhaseAcute Phase
Patient Education:
Clear explanations for all care/treatments
Focus on improvements—regained abilities
Include family