Question

Mr. Ali, the 56-year-old man admitted with a stroke, has many abnormal findings.

He has a history of hypertension, smoking, and mild baseline dementia. He appears fearful and agitated, asking for cigarettes, oriented to name only. His speech is comprehensible but slurred.

Mr Ali is drowsy with periods of confusion. He has impaired short-term memory—remembers zero of three objects after 1 minute. He appears to have left visual field loss. He has right lower facial weakness left tongue deviation. His muscle bulk is symmetrical, tone slightly increased on left arm/leg. He has diminished attention to objects and people on the right side of bed.

C-what nursing care plan should the nurse formulate to the patient ?

Answer 1

Subjective Data:

· Drowsiness

· Confusion.

· left visual field loss

· Impaired short-term memory.

· right lower facial weakness left tongue deviation

· Decreased sensation

Objective Data:

· Hemi paresis

· Hemiplegia

· Ataxia

· Dementia

· Facial droop

· Paralysis

· Aphasia

Nursing Interventions and Rationales

· Frequent neurological assessments (per orders)

      Alerts nurse to neurological changes as early as possible, enables them to notify   

      MD and intervene when needed

· HOB at 30 degrees unless otherwise indicated

Decreases ICP by:

· Improving venous return

· Minimizing intrathoraxic pressure

· Initiate DVT prophylaxis (mechanical and/or chemical)

· Ensure PT/OT is ordered

must complete a baseline assessment and provide recommendations

· Promote adequate nutrition

Nutrition

· Consult Speech Therapy for swallow evaluation PRIOR to oral intake

All stroke patients are NPO until cleared by Speech Therapy due to high risk of dysphagia and aspiration. Frequently, brain injury results in an impaired ability to swallow safely. This is not always apparent as patients don’t always cough when aspirating and have silent aspiration. A bedside swallow evaluation can be done by the nurse, but will only clear the patient for PO meds, not for PO intake of food/fluids

· Prevent aspiration: follow ST recommendations, keep HOB at 45 degrees during oral intake and keep patient upright after a meal, have suction available, assess lung sounds and body temp

Stroke patients frequently have impaired swallowing, and are at high risk for aspiration from their own oral secretions and oral intake.

Once a patient is cleared to eat, do what you can to encourage appropriate intake. Patients cannot heal if they don’t eat.

· Fall prevention measures (non-skid socks, bed in lowest locked position, call bell within reach, and so forth)

Injury prevention; patient will most likely not be able to ambulate as well as they could prior to stroke and will require assistance

Enhance memory

• Encourage memory aids – e.g., calendar, white board, daily planner if the resident is able to read, recorded voice reminder if the resident is unable to read.

•Patiently repeat information to help the resident remember it.

• Provide simple, clear information that focuses on the information the resident needs. • Store items in the same places.

• Ensure drawers and cupboards are clearly labelled with their contents.

Aid with treatment of underlying problem (Hypertension and smoking)

orient patient to surroundings

Modulate sensory exposure.

Provide a calm environment; eliminate extraneous noise and stimuli.

Encourage family to participate in orientation as well as providing ongoing input.

Increased levels of visual and auditory stimulation can be misinterpreted by the confused patient.

Give simple directions. Allow sufficient time for patient to respond, to communicate, to make decisions.

· Prevent contractions

Extremities that are now paralyzed are at risk for becoming contracted; ensure pillow supports are in place, as well as rolled towels in hands and adaptive devices

· Cluster care; promote rest

Maximizes time with the patient so he can rest when care is not being provided

· Monitor vital signs appropriately; know BP limits

Closely monitoring BP is essential in managing ICP so that we can ensure an appropriate CPP.

· Promote cerebral tissue perfusion (interventions differ depending on kind of stroke, location, and other factors). This prevents additional neurological damage. (MAP – ICP = CPP)

· Prevent edema:

o Elevate limbs

o Utilize compression stockings

o Promote ambulation

o Promote complete bladder emptying

· Promote self-care

Patient may  have decreased ability to care for self due to new deficits. Promote confidence and participation in caring for themselves as much as possible. Provide adaptive devices and alternate strategies for ADL’s

· Prevent skin breakdown:

o Turn q2hrs

o Ensure adequate protein intake

o Off-load pressure areas

o Pillow support

o Keep linen clean and dry

· Facilitate communication; promote family coping and communication.

Nursing Diagnosis

1. Ineffective Cerebral Tissue Perfusion

2. Impaired Physical Mobility

3. Impaired Verbal Communication

4. Disturbed Sensory Perception

5. Ineffective Coping

6. Self-Care Deficit

7. Risk for Impaired Swallowing

8. Activity Intolerance

9. Risk for Unilateral Neglect

10. Deficient Knowledge

11. Risk for Disuse Syndrome

12. Risk for Injury

Ineffective Cerebral Tissue Perfusion

Nursing Diagnosis

· Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

Related Factors

Common related factors for this nursing diagnosis:

· Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vaso­spasm, cerebral edema

Defining Characteristics

The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.

· Altered level of consciousness; memory loss

· Changes in motor/sensory responses; restlessness

· Sensory, language, intellectual, and emotional deficits

· Changes in vital signs

Desired Outcomes

Common goals and expected outcomes:

· Patient will maintain usual/improved level of consciousness, cognition, and motor/sensory function.

· Patient will demonstrate stable vital signs and absence of signs of increased ICP.

· Patient will display no further deterioration/recurrence of deficits

Nursing Interventions and Rationales

Here are the nursing assessment and nursing interventions for stroke nursing care plan.

Nursing Interventions	Rationale
Nursing Assessment
Assess factors related to individual situation for decreased cerebral perfusion and potential for increased ICP.	Assessment will determine and influence the choice of interventions. Deterioration in neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies. If the stroke is evolving, patient can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence.
Closely assess and monitor neurological status frequently and compare with baseline.	Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.
Monitor vital signs:
· Changes in blood pressure, compare BP readings in both arms.	Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse). Increased ICP may occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by difference in pressure readings between arms.
· Heart rate and rhythm, assess for murmurs.	Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (stroke after MI or from valve dysfunction).
· Respirations, noting patterns and rhythm (periods of apnea after hyperventilation), Cheyne-Stokes respiration.	Irregularities can suggest location of cerebral insult or increasing ICP and need for further intervention, including possible respiratory support.
Evaluate pupils, noting size, shape, equality, light reactivity.	Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves.
Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.	Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.
Assess higher functions, including speech, if patient is alert.	Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP.
Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.	Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP or cerebral injury, requiring further evaluation and intervention.
Therapeutic Interventions
Position with head slightly elevated and in neutral position.	Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures.	Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.
Prevent straining at stool, holding breath.	Valsalva maneuver increases ICP and potentiates risk of rebleeding.
Administer supplemental oxygen as indicated.	Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation.
Administer medications as indicated:
· Alteplase (Activase), t-PA;	Thrombolytic agents are useful in dissolving clot when started within 3 hr of initial symptoms. Thirty percent are likely to recover with little or no disability. Treatment is based on trying to limit the size of the infarct, and use requires close monitoring for signs of intracranial hemorrhage. Note: These agents are contraindicated in cranial hemorrhage as diagnosed by CT scan.
· Anticoagulants:	May be used to improve cerebral blood flow and prevent further clotting when embolism and/or thrombosis is the problem.
· Antifibrinolytics:	Used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding.
· Antihypertensives	Chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage.
· Peripheral vasodilators:	Transient hypertension often occurs during acute stroke and resolves often without therapeutic intervention.Used to improve collateral circulation or decrease vasospasm.
Steroids:	Use is controversial in control of cerebral edema.
· Neuroprotective agents: calcium channel blockers, excitatory amino acid inhibitors, gangliosides.	These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical events (influx of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acid) to limit ischemic injury.
· Stool softeners.	Prevents straining during bowel movement and corresponding increase of ICP.
Monitor laboratory studies as indicated: prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) time, Dilantin level.	Provides information about drug effectiveness and/or therapeutic level.