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                   Module 9: Neurosensory Disorders: Stroke
                         Marnie Quick, RN, MSN, CNRN

                          STROKE (CVA, Brain Attack)

These notes are an expansion of the Lewis textbook required readings.
Please use them together.

Etiology/Pathophysiology of Stroke
   1.   Normal brain physiology as it relates to stroke.
            a. Blood supply to the brain (Lewis 1451 Fig 56-13; 1452 Fig 56-14;
                1504 Fig 58-1) Two major arteries, Circle of Willis, cerebral arteries.
            b. Characteristically strokes affect one side (hemisphere) of the brain;
                hence the terms right CVA and left CVA. Neurologic deficits occur on
                the contralateral (opposite) side of the stroke.
            c. Severity of loss of function varies according to the location and
                extent of brain involvement.
            d. A functioning brain depends on continuous blood supply to provide
                oxygen and glucose, and to remove the end products of metabolism.
                Changes seen in the brain with 4-5 minutes of lack of blood.
            e. With lack of blood to the area, brain cells swell decreasing blood
                supply. Penumbra is the central core of dead cells surrounded by a
                band of minimally perfused brain cells. If collateral circulation is
                established quickly, brain cells may survive. Brain cell death 5 min.
            f. Regulation of cerebral blood flow in regard to autoregulation and
                increased intracranial pressure is important with strokes and will be
                discussed with module 10. Other factors BP; CO; blood viscosity.
            g. CVA is third leading cause of death in North America; major cause of
   2.   Risk factors for stroke:
          a. Nonmodifiable- age, gender, race family history/heredity
          b. Modifiable- Hypertension*; atherosclerosis* (Lewis 1505 Fig 58-2);
               heart disease; Diabetes Mellitus; medications- birth control pills,
               substance abuse as cocaine, heroin, alcohol; sedentary life style;
               obesity; high cholesterol diet; smoking; stress; sickle cell disease.
   3.   Length of time between lack of blood supply and brain dysfunction.
            a. How long the lack of blood supply depends on adequacy of collateral
                circulation and the amount of brain edema.
            b. Terms used to describe how long without blood to the brain.
                    1)    Transient Ischemic Attack (TIA)- Neuro deficits last less
                          than 24 hrs. Most resolve within 3 hrs. Warning sign of
                          progressive cerebrovascular disease.
                    2) Reversible Ischemic Neuro Deficits (RIND)- Neuro deficits
                         last over 24 hrs, but not greater than 21 days and are
                    3)    Stroke/Cerebral Vascular Accident (CVA)/Brain attack-
                          Irreversible brain damage with residual neuro deficits.
   4.   Disease process- pathophysiology of the two basic causes of stroke (Lewis
        1505 Fig 58-3 and 1506 Table 58-1)
            a. Ischemic (occlusive) stroke (80%)
       1) Generally strokes caused by occlusion of the artery.
          Individuals generally do not lose consciousness, have a
          better prognosis than hemorrhagic.
     2) Thrombosis is caused by a narrowing of an artery from
          atherosclerotic plaque. This narrowing blocks the blood
          supply to a part of the brain that the artery supplies. It
          often occurs in older individuals who are at rest/sleeping. It
          is the most common cause of a stroke (60%). Thrombi tend
          to form in large arteries that bifurcate, internal carotid
          artery is common site. Can begin as TIA’s before having a
            stroke; can have a stroke-in-evolution over a period of 3
            days, or can experience a completed stroke outright.
          Lacunar strokes are strokes affecting smaller cerebral
          vessels in the brain, they leave a small cavity- or ‘lake’.
     3)   Embolic stroke is caused by clotted blood (from other
          arteries in the body- most common from heart during
          arrthymias as atrial fibrillation), fat, bacteria (bacterial
          endocarditis) or air. The emboli circulates until it reaches an
          artery in the brain that is too narrow to pass through.
          Usually awake, have a headache and tend to have a rapid
          onset and the extent of damage is less severe and recovery
          faster than other causes of stroke. Will recur if don’t treat
b. Hemorrhagic stroke (15%)
     1)   Generally occurs during activity, has a rapid onset, more
          likely to cause loss of consciousness and has a poorer
          prognosis than occlusive.
     2)   Intracranial hemorrhage (ICH) is caused by a ruptured
          artery in the brain. Bleeding varies in size from petechial to
          massive, edema occurs around the bleed. The blood may
          form a hematoma or be diffuse within the brain. Usually
          occurs rapidly with the deep arteries and hypertension is
          the main cause. Most common cause of death due to a
          stroke. These individuals typically will have more extensive
          residual deficits and a slower recovery than other causes of
     3) Subarachnoid hemorrhage (SAH) is caused by bleeding into
          the subarchnoid space from intracranial hemorrhage, a
          berry (sacular) aneurysm or AV malformation. Usually
          occurs in younger adults (30-60 yrs)
              a. Aneurysms occur at bifurcations, branches of carotid
                 arteries and vertebrovascular arteries. 85% in
                 anterior circulation at the base of the brain. Caused
                 by trauma, congenital, arteriosclerosis.
              b. The most common type is a berry aneurysm. They
                 rupture from dome (top) forcing blood into
                 subarachnoid space at the base of the brain. Blood
                 can then flow into the ventricles and brain tissue.
              c. Fusiform aneurysms- circumference of blood vessel
                 elongated tube from arteriosclerosis.
              d. A-V malformations are congenital abnormal joining of
                 arteries to veins in the brain. Become a tangled
                 collection of dilated vessels. Ischemia symptoms first
                              as there is loss of blood flow- Pressure changes
                              usually cause the malformations to bleed.
                           e. Ruptured aneurysm symptoms- sudden explosive
                              headache; loss of consciousness; nausea and
                              vomiting; nuchal rigidity (stiff neck) and photophobia
                              from meningeal irritation; cranial nerve deficits;
                              stroke syndrome.
                           f. Aneurysm are graded 0-V on the Hunt and Hess
                              scale; the higher the number the poorer the chance
                              for survival. Grading is based on LOC and quality of
                              cerebral function.
                           g. The major complications of SAH are rebleed
                              (absorption of the clot stopping the bleed),
                              vasospasms (irritation of the blood vessels), and
                              hydrocephalus (from blockage of the absorption of

Common Manifestations/Complications of Stroke
  1. Severity of the loss of function varies according to the location and extent of
     the brain involved.
  2. Artery affected by occlusion/hemorrhage will present with the following
     symptoms: (Lewis 1507 Table 58-2)
         a. Internal carotid- affects whole hemisphere (Lewis 1508 Fig 58-5)
                1)    Left brain hemisphere (Left CVA) Usually referred to as the
                      dominant hemisphere, because Dr. Broca first identified the
                      speech center on the left side. All right-handed individuals,
                      but is also considered dominant in some left-handed
                      individuals. Specific symptoms Lewis 1508 Fig. 58-5.
                2)    Right brain hemisphere (Right CVA) Usually referred to as
                      the nondominant hemisphere, but it is dominant for spatial-
                      perceptual. Specific symptoms Fig. 58-5.
         b. Middle cerebral artery (Lewis 1507 Table 58-2)
                1)    Contralateral motor loss in the arm and the lower part of
                      the face (central facial palsy-UMN palsy); hemiparesis=
                      weakness or hemiplegia= paralysis
                2)    Contralateral sensory loss in face and arm
                3)    Homonymous hemianopsia
                4)    If left middle cerebral artery- communication deficits
                5)    If right middle cerebral artery- spatial/perceptual deficits
         c. Anterior cerebral artery, posterior and verebrobasilar (Table 58-2)
  3. Motor deficits
         a. The motor nerve pathways cross in the medulla; therefore a right
            CVA affects the left side of the body; left CVA, affects the right. The
            prefix hemi- is used to describe.
         b. Amount of motor involvement varies from weakness (-paresis) to
            paralysis (-plegia). Paralysis can be flaccid (absence of muscle tone-
            hypotonia) in type or spastic (increased muscle tone with weakness)
            depending on the amount of brain damage to the motor strip
            (prefrontal gyrus). Hemiplegia means paralysis of half the body,
            however extremities not affected equally. Arm may have greater loss
            than leg, as with middle cerebral artery CVA.
         c. Affected extremities are initially flaccid and become spastic in 6-8
            weeks. There is a characteristic body posturing- adduction arm,
           pronation of forearm, flexion of fingers, extension hip, foot drop, and
           outward rotation of leg, and dependent edema.
        d. Facial palsy: can be whole side of face involved Bell’s Palsy (LMN
           palsy- facial (7th) cranial nerve affected) and/or can have the lower
           part of the face is involved (called UMN palsy or central palsy- the
           cerebral hemisphere motor strip affected)
        e. Dyphagia is motor loss resulting in difficulty swallowing.
4.   Sensory deficits
        a. Lack of/decrease in sensation; inability to perceive/interpret pain;
           touch, pressure, etc. because of stroke affecting the post central
           gyrus, the sensory strip. Contralateral side of the body
        b. Lack of/decrease in proprioception. Difficultly in knowing where body
           part is without having to look at it; proprioception is the body’s
           ‘position sense’.
        c. Visual field deficits
               1)     Disruption can occur anywhere along the optic nerve, optic
                      track, optic radiation or occipital lobe of the brain.
               2)     Homonymous hemianopia- Most common visual field deficit
                      in stroke. Loss of half of visual field in each eye. Individual
                      can not see toward the same side in both eyes. Individual
                      cannot see objects that are on the same side toward their
                      paralysis; such as one half of meal tray or one half of a
                      sign. Usually seen with middle cerebral artery stroke.
5.   Communication disorders
        a. Includes motor, speech, language, memory, reasoning, emotions.
        b. The brain has different centers for different modes of
           communication. These brain centers are affected in varying degrees
           dependent on the amount of damage or interference with the
           pathways. These brain centers are in the dominant hemisphere,
           which is the left hemisphere for most people- all right-handed
           individuals and about 70% of left-handed individuals.
        c. Can experience aphasia (total loss of comprehension or use of
           language) or dysphasia (partial loss or difficulty with comm.)
        d. Normal process of recovery as brain edema subsides individual will
           begin saying one word speech (swearing, ouch, etc); then progress
           to sayings (days of the week, social speech- ‘how are you’, singing,
           etc); then volitional (normal) speech.
        e. Improvement may stop at any point, depending on the amount of
           damage to speech centers.
        f. Expressive
               1)     Also called Broca’s (verbal center) or nonfluent.
               2)     Difficulty is in talking, expressing self in writing or use
                      gestures. May not affect all expressive areas equally.
               3)     May understand speech.
               4)     Normal process of recovery as brain edema subsides
                      individual will begin saying one word speech (swearing,
                      ouch, etc); then progress to sayings (days of the week,
                      social speech- ‘how are you’, singing, etc); then if full
                      recovery occurs will have volitional (normal) speech.
               5)     Improvement may stop at any point, depending on the
                      amount of damage to speech centers.
         g. Receptive
                 1)    Also called Wernicke’s (verbal understanding center) or
                 2)    Inability to understand communication- verbal, written or
                       gestures to varying degrees
                 3)    Able to talk but does not always make sense.
         h. Global or Mixed- both expressive and receptive affected.
         i. Dysarthria
                 1)    Difficulty with the mechanics of speech- articulation or
                       muscular control for speech. This causes difficulty with
                       pronunciation, articulation or phonation. Sound like they
                       have mashed potatoes in their mouth.
6.   Affect and intellectual functioning
         a. Changes in level of consciousness- confusion to coma
         b. Emotional responses may be exaggerated or unpredictable.
             Emotional lability is considered physiological, not emotional in
             nature. Best to divert the client’s attention.
         c. Loss of self control and decrease tolerance for stress (quick to anger)
         d. Depression, frustration with mobility and communication problems.
         e. Intellectual changes resulting in memory loss, decreased attention
             span, poor judgment, inability to think abstractly and to make
7.   Spatial-Perceptual deficits- more common with right CVA
         a. Patient may or may not be aware of these deficits
         b. Incorrect perception of self and illness.
               1) Deny there is a problem or illness.
         c. Erroneous perception of self in space- Neglect Syndrome (Unilateral
                 1)    Attention disorder in which individual ignores affected part
                       of body, cannot integrate or use perceptions from affected
                       side of body or from environment on affected side.
                 2)    May observe that client has head turned away from
                       neglecting side, does not dress that side of the body,
                       neglects person or objectives on that side. If have paralysis,
                       then neglect is toward that side.
                 3)    Have difficulty judging distances.
                 4)    May have associated deficits which complicate neglect, such
                       as Homonymous hemianopia.
         d. Agnosia
                 1)    Inability of the senses to perceive stimuli that were
                       previously familiar. May be any of the senses and in varying
                       degrees.(See assessment section for examples)
         e. Apraxia
                 1)    Inability to carry out purposeful tasks in the absence of
                       paralysis, or the individual carries out the task
                       inappropriately. (See assessment section for examples)
8.   Elimination disorders
         a. Partial loss of sensation can affect the perception of need to
             eliminate bladder and bowel. May have urinary frequency,
         b. Cognitive problems may affect the social aspect of elimination.
         c. Level of consciousness, immobility, dehydration, diet changes can
             affect elimination of the individual with a stroke.
   9.    Any of the complications from immobility can occur- orthostatic
         hypotension, increased thrombus formation, impaired respiratory function
         formation of renal calculi, decreased cardiac output, osteoporosis, decubitus
         ulcer formation, contractures

Collaborative Care for a Stroke
   1.   Diagnostic tests for strokes (Lewis 1509 Table 58-3)
            a. Diagnosis of stroke, including extent of involvement
               1. CT is the most important initial diagnostic study. Obtain within 25
                    min and read within 45 min of arrival at ER. Will indicate size and
                    location of lesion; differentiate between ischemic/hemorrhagic
                2. PET scan- cerebral blood flow distribution and metabolic activity
                3. MRI or MRA (combined MRI with arteriogram)
            b. Cerebral blood flow measures-
                1. Arteriogram- abnormal vessel structures; vasospasms; stenosis
                2. Transcranial ultrasound Doppler- velocity of blood flow, degree of
            c. Cardiac assessment
                1. Cardiac monitoring and tests to see if underlying cardiac
                    condition- EKG; cardiac enzymes
            d. Other- Lumbar puncture obtain CSF, look for bleeding (physician
                does if no danger of IICP); bl studies-CBC, lipid, platelets, glucose
   2.   Collaborative Preventive Care (Lewis 1510 Table 58-4 plus table above it*;
        Fig 58-6 endartectomy; Fig 58-7 stent)
            a. Management of modifiable risk factors
            b. Medications
            c. Surgical therapy-Endarterectomy, angioplasty, stenting, EC-IC bypass
   3.   Collaborative Acute Care: Emergency Management (Lewis 1511 Table 58-5)
            a. Etiology, assessment findings and interventions (initial and ongoing)
   4.   Collaborative Acute Care: Thrombotic stroke
            a. Medication
                    1)    Tissue plasminogen activator (tPA) (such as Activace) to
                          dissolve clots; must be given within 3 hrs from onset of
                          stroke. There is a set protocol- must rule out hemorrhage
                          (by CT), recent surgery, etc.
                    2)    Anticoagulants (Heparin, Coumadin) to prevent further
                          extension of stroke.
                    3)    Antithrombotic- inhibit platelet phase of clot formation.
                          Aspirin, Ticlid, Plavix
                    4)    Anticonvulsants (prevent seizures 7% may have after CVA)
            b. Surgical intervention
                    1)    Endarterectomy (Lewis Fig 58-6)
                    2)    Angioplasty, carotid artery stenting (Lewis Fig 58-7)
                    3)    Bypass- superficial temporal artery ananamosted to the
                          middle cerebral artery
   5.   Collaborative Acute Care: Embolic stroke
            a. Medications to treat the type of embolism
                    1)    If blood embolism- anticoagulants; Tissue pasminogen
                          activator (tPA); antiarrhythmics
                    2)    If bacterial embolism- antibiotics
            b. Surgical
                  1) Embolic retrieval- catheter inserted through femoral artery to
                      cerebral artery and remove clot through catheter (Lewis 1513
                      Fig 58-10 Merci retriever)
   6.    Collaborative Acute Care: Intracranial Hemorrhage (ICH)
             a. Bedrest
             b. Medication- antihypertensives to maintain normal blood pressure
             c. Surgical- remove hematoma-may not be able to if bleed throughout
                brain tissue.
   7.     Collaborative Acute Care: Subarachnoid Hemorrhage (SAH)
             a. Aneurysm precautions (decrease external and internal stimuli)
             b. Medication for aneurysms
                      1)    Medications that aide with aneurysm precautions; stool
                            softeners, anti nausea, for headache, to sedate
                      2)    Medications that prevent rebleed:
                                - Aminacproic Acid (Ammicar) fibrolysis inhibitor to
                                   prevent lysis of the formed clot- prevent rebleed
                                - Medications to normalize blood pressure
                      3)    Medications to prevent vasospasms
                                - Prevention of vasospasms before surgery- Calcium
                                   Channel blocker- Nimodipine (specific for cerebral)
                                - Prevention of vasospasms after surgery- ‘Triple H
                                   therapy’ (hypertension, hypervolemia and
                                   hemodilution)-- vasodilators (Isuprel); induced
                                   arterial hypertension (Dopamine); hypervolemic
                                   hemodilution (Albumin)
                      4)    Prophylactic antiepileptic drugs- Cerebex/Dilantin
             c. Surgical intervention (Lewis 1512 Fig 58-8; Fig 58-9)
                      1)    Aneurysms- done to prevent rupture or isolate vessel to
                            prevent further bleeding. If patient unstable may delay
                            surgery. Clip aneurysm, wrapping with synthetic wrap or
                            muscle, insert endovascular coils.
                      2)    A-V malformation- embolization, ligation of feeders, laser
                            surgery to remove malformation.
             d. Gamma Knife- radiation to reduce size of A-V malformation
 7. Collaborative Rehabilitation care
        a. Physiatrist (rehab physician), physical therapy, occupational therapy,
            speech therapy, cognitive therapy, etc.
        b. Exercise program (Lewis 1514- Evidence-Based Practice)
        c. The individual with a stroke may return home (in-home rehabilitation),
            go to a rehabilitation center (in-house or outpatient) or may be placed in
            a nursing home.
        d. Home evaluation by rehabilitation team is needed!
        e. Encourage self-care as much as possible with family involvement
        f. Community resources should be evaluated for each individual with a
            stroke, including family support.

Nursing Assessment Specific to Stroke
  1.   Subjective data (Lewis 1514 Table 58-6)
          a. Health information- Past health history- risk factors, including
              hypertension; family health history- stroke or cardiovascular disease.
              Medications, both legal and illegal
          b. Functional health patterns- health perception, nutritional, activity,
              expresses stroke symptoms
2.   Objective data (Lewis 1514 Table 58-6)
        a. General, respiratory, cardiovascular, gastrointestinal, urinary, neuro
3.   Assessing for neuro deficits common to stroke
        a. Assess level of consciousness- Refer to Module 10
        b. Assess motor function
                1)   Movement, strength (with and with resistance), symmetry
                     of all extremities.
                2)   Pronator drift will detect weakness of upper extremity
                     (should be able to extend arms in front with palm up, eyes
                     closed, for 20 seconds without drifting and pronating
                3)   Use similar techniques that were used to assess motor
                     function as discussed with spinal cord injury. However,
                     remember that the motor pathways that are affected in
                     stroke begin in the brain- the motor strip in the frontal
                4)   Test facial movement- tell the individual to smile/frown This
                     tests both upper and lower part of the face (Bell’s Palsy, 7th
                     CN affects whole side of face has paralysis; or central palsy
                     where the lower side of face has lack of movement and
                     results in a dropping mouth).
                5)   Test eye movements (EOM’s)- Have the individual with their
                     head still, follow your finger in all quadrants. Eyes should
                     move together (conjugate eye movements) Abnormal:
                     dysconjugate gauze, nystagmus, 3rd nerve palsy, 6th nerve
                6)   Assess for tongue deviation- have patient stick out there
                7)   Test ability to swallow, gag reflex. Dysphagia- difficulty
                8)   Flex neck: Testing for stiffness of the neck (nuchal rigidity)
        c. Assess ability to void and move bowels.
        d. Assess the sensory and perceptual functions
                1)   Superficial sensation- with a cotton tip applicator broken in
                     half (as utilized when testing sensation in the spinal cord
                     individual) and with their eyes closed, ask if feel sharp or
                     dull. Remember that your reference for the stroke patient
                     is in the sensory pathways in the brain- the sensory strip
                     (precentral gyrus)(Lewis 1447 Fig 56-7) in the parietal lobe
                     and not the dermatones (for SCI).
                2)   Proprioception- ‘position sense’. Assess by having the
                     individual close their eyes and holding the toe on the sides,
                     move the toe up and down (not touching the other toes),
                     stop, then ask if the toe is up or down.
                3)   Vision- Assess for visual field loss by having the individual
                     look straight ahead, cover one eye and move your wiggling
                     finger into their field of vision from 4-6 directions. Patient
                     should state when first sees. Common deficit in stroke is
                     homonymous hemianopia- unable to see toward their
                     paralyzed side. (Lewis 1520 Fig 58-11)
                4)   Agnosia- Examples:
                          – Visual agnosia: individual becomes lost on the unit;
                             cannot read signs/symbols; difficulty estimating
                                  distance (spills food); cannot find objects; does not
                                  recognize faces on photo or own image.
                              – Auditory agnosia: individual appears bewildered by
                                  sounds and does not respond appropriately like a
                                  phone ringing; cannot identify sound as running
                                  water, airplane; words may sound like gibberish.
                              – Tactile agnosia (astereognosis): Individual with there
                                  eyes closed can’t recognize familiar objects such as
                                  comb, toothbrush, pencil; unaware of location or
                                  recognize body parts; difficulty positioning self,
                                  slouches to one side, poor balance and difficulty
                    5)    Apraxia- Examples: Combs hair with toothbrush; puts shirt
                          on legs; stares at food tray unaware of how to get food to
                    6)    Unilateral neglect- Examples: Ignores paralyzed arm or leg,
                          may claim it is not theirs; bumps into wall as going down
                          hall; unaware of objects placed on paralyzed side. (See
                          manifestations above)
                    7)    Postural stability- tend to fall sideways when in chair. (Lewis
                          1521 Fig 58-12)
            e. Assess communication ability- (Lewis 1520 Table 58-8; See
                manifestations above)
            f. Assess cognitive and behavioral aspects-(See manifestations above)
   4.    National Institute of Health (NIH) Stroke Scale-
            a. An assessment scale to reflect the degree of neurologic dysfunction
                from a stroke.
            b. A high score correlates with a large stroke.
            c. Scale based on level of consciousness, gaze, visual, facial palsy,
                motor, ataxia, sensory, language, dysarthria, and extinction and
                inattention (also called neglect). See Web site for form:

Pertinent Nursing Problems and Interventions for Stroke
   1.   *Lewis 1516 Nursing Care Plan 58-1
   2.   Ineffective tissue perfusion (Cerebral) also add-
           a. Monitor respiratory status; provide oxygen; suction as needed.
           b. Monitor neurological, specifically increasing neuro deficits, seizures,
               and increased intracranial pressure
           c. Monitor cardiac status, specifically dysrhythmias (esp A fib)
           d. Monitor for seizure activity
           e. If the individual is unconscious (usually seen with hemorrhagic
               stroke), provide coma care.
   3.   Ineffective airway clearance
   4.   Impaired physical mobility
           a. Encourage active (when possible) and passive ROM
           b. Change position q 2hrs, especially if comatose
           c. Monitor/prevent thrombophlebitis
           d. Work with Rehabilitation team- physical therapy, occupational
               therapy, speech therapy, cognitive therapy, etc.
           e. Have rehabilitation team assess need for:
                 1)   Arm sling- used to prevent subluxation of the shoulder*
                      from a paralyzed upper extremity when the individual is out
                      of bed
                  2) Splints- hand/foot splints to prevent contractures. Generally
                      a schedule is set up- 2 hrs on; 2 hrs off. This is combined
                      with ROM.
                  3) Ambulatory and other assistive devices.
5.   Impaired verbal communication
         a. Assess speaking, writing, gestures, understanding
         b. Support speech therapist plan
         c. Support guidelines, such as use of picture board.
         d. Remember swearing may be the first sign of return of speech, not
             intended to be directed at you or family.
6.   Unilateral neglect
7.   Impaired urinary elimination
8.   Impaired swallowing
        a. Dysphagia- difficulty swallowing
        b. Oatmeal/pudding consistency for mild dysphagia.
        c. Provide safety when eating!! Assess ability, head of bed up, begin
            with food with consistency (such as oatmeal), place food on
            unaffected side, have patient think swallow.
        d. Occupational therapy and/or speech therapy can evaluate the
            individuals’ ability to get food to the mouth and to swallow.
        e. Swallow studies done under fluoroscope to visualize swallowing with
            various consistencies to determine what is appropriate for client
9.   Situational low self-esteem
10. Self-Care deficit
        a. Encourage use of paralyzed extremity
        b. Teach dressing techniques- affected arm in clothing first, etc
        c. Work with rehabilitation team regarding ADL’s, use of assistive
            devices, and plans for progress, including home care.
        d. Allow time and provide encouragement when performing ADL’s.
        e. Assess both physical and cognitive ability to perform self-care.
        f. With agnosia- encourage patient to use other senses to make up for
            lost sense
        g. With apraxia- break complex tasks down into simple steps; have a
            single item out at one time- such as only toothbrush; use colored
            labels on clothes or Velcro on one sleeve to help identify correct
            extremity; allow time and encourage independence.
        h. With perseveration- may have to tell person to stop action that they
            are perseverating about or may have to physically stop them.
        i. With homonymous hemianopsia in the acute phase approach from the
            sighted side, as the client progresses- teach and encourage the client
            to scan the room, meal tray, etc.
 11. Nursing Management of the following:
        a. Health promotion- Teach risk factors, prevention, early symptoms
            (Lewis 1515 Table 58-7)
        b. Respiratory system
        c. Neurologic system
        d. Cardiovascular system
        e. Musculoskeletal system
        f. Integumentray system
        g. Gastrointesttinal system
      h. Uninary system
      i. Nutrition
      j. Communication
      k. Sensory-perceptual alterations
      l. Affect
      m. Coping
12. Ambulatory and Home Care
     a. Rehabilitation
     b. Musculoskeletal function
     c. Nutritional Therapy
     d. Bowel function
     e. Bladder function
     f. Sensory-Perceptual function
     g. Affect
     h. Coping
     i. Sexual function
     j. Communication
     k. Community integration