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					                         RNSG 2432 ONLINE NOTES
                   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
                disability.
   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
                         reversible.
                    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%)




                                                                       RNSG 2432  241
                  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
                     cause.
           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
                     stroke.
                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 vertebrobasilar 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



242  RNSG 2432
                              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
                              CSF)

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,



                                                                     RNSG 2432  243
              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.




244  RNSG 2432
         g. Receptive
                 1)    Also called Wernicke’s (verbal understanding center) or
                       fluent.
                 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
             generalizations.
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
             neglect)
                 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,
             incontinence.
         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.



                                                                    RNSG 2432  245
   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 occlusion.
            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



246  RNSG 2432
                   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
   8.   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



                                                                     RNSG 2432  247
           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, NVS
   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
                        downward).
                   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
                        cortex.
                   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
                        palsy.
                   6)   Assess for tongue deviation- have patient stick out there
                        tongue.
                   7)   Test ability to swallow, gag reflex. Dysphagia- difficulty
                        swallowing
                   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:



248  RNSG 2432
                            –    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
                                 walking.
                   5)    Apraxia- Examples: Combs hair with toothbrush; puts shirt
                         on legs; stares at food tray unaware of how to get food to
                         mouth
                   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. The Scale is 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 utilized,
               directions and know how to test:
               http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
           c. Know how to test for each aspect using the tool found on the website
           d. NIH Stroke Score guidelines for measuring stroke severity:
                   0= no stroke
                   1-4= minor stroke
                   5-15= moderate stroke
                   15-20= moderate/severe stroke
                   21-42= severe stroke
                   A maximal score of 42 represents the most severe and
                     devastating stroke.
           e. As of 2008, stroke patients scoring greater than 4 points can be
               treated with tPA. -If meet other criteria (no hemorrhage (by CT), no
               recent surgery, etc) and follows the protocol of hospital.
   5.

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.




                                                                       RNSG 2432  249
             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.



250  RNSG 2432
      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




                                                                RNSG 2432  251
252  RNSG 2432

				
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