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