Question

Chief Complaint: "Worst headache of his life"History of Present Illness: On Sunday afternoon while Mr.O was at home visiting with his wife and the family of his youngest son, he experienced a sudden, severe headache which he described to his wife and son as"the worst headache of his life."Within minutes, he experienced numbness and weakness of his left face, arm, and leg and wash having increasing difficulty speaking and understanding simple statements. His wife called 911, and by the time the ambulance arrived, his level of consciousness' was declining and he was making incomprehensible sounds. He met all six criteria on the Los Angeles prehospital stroke scale. IV and oxygen therapy was initiated, and Mr.O was transported to the emergency department. Upon arrival at the emergency department, Mr.O was found to have a GlasgowComa Scale of 4(does not open eyes with painful stimuli, an abnormal extension of right extremities to painful stimuli, no movement of the left extremities, and no verbal response). His pupils were unequal with the left pupil 1mm lager than the right pupil 4mm/3mm, and both pupils had a sluggish reaction to light. His blood pressure was190/110, and pulse oximetry was 93% on oxygen therapy of 2 liters per nasal cannula. His CT scan revealed a large right internal capsule intracerebral hemorrhage.EKG showed normal sinus rhythm, left axis deviation with right bundle branch block. PAC XR showed heart size and pulmonary vasculature within norma llimits.No opacification or pleural effusions.Lab's done during acute care admission:RBC4.01,WBC4.6,Hgb14.2,Hct45,platelets300,glucose104,Na139,K4.5,Cl105,CO228,CHOL211,triglycerides180,HDL39,LDL117,HDL/LDL5.41,PT11.6,INR1.0,PTT35,blood alcohol 100.Prognosis and treatment options were discussed with Mr.Oishi's wife and youngest son.Mrs.O in light of poor prognosis declined any treatment that includes invasive procedures. The youngest son disagrees with his mother and has requested more aggressive therapy. Mr.Oishi was transferred to the ICU Sunday night while arrangements could be made for hospice care in a skilled nursing facility. Mr.O received Nitroprusside 50mg in 250mLD5W to titrate systolicBP<140>110,Mannitol25%solution to decrease intracranial pressure,Famotidine 20mg,IV to prevent stress ulcers,and IV therapy of D5 NS with 20mEqKCl at100mL per hour. on Monday morning, Mr. Oishi's blood pressure stabilized as a systolic BP of 140-150. The Nitroprusside and Mannitol were discontinued. He was transferred to skilled nursing for hospice care. Allergies: None is known to food or medication. Past medical history: Hypertension for the past10years which has been controlled by medication(Amlodipine/Benazepril2.5/10mgeverymorning)until the past year when he began experiencing a high degree of stress over his company failing. Hyperlipidemia for the past 5years controlled by medication(Atorvastatin20mgatbedtime).No hospitalizations.SurgicalHistory: None Gyn History: N/AOBHistory: N/ASocialHistory: Mr.Goro Oishi has been married to Mrs.H O for 40years.He enjoys sales e and happy relationships with his wife. He has 2 married sons age 32and37. His youngest lives in town and his oldest son live out of town.Mr.O is the owner and CEO of as mall electronics company that up until a year ago was doing well. This past year the company has been failing.Mr.Oishi has been under a great deal of stress. He has been abusing alcohol for the past 6months and has been hiding it from his wife and sons. His wife has suspected that he was abusing alcohol but never confronted him.Mr.O has been discussing retiring and having his youngest on taking over the position of CEO of the company. Now that the business is failing he fears she will have no way to support his family. Pt was comatose. Family fears that Mr. O will die. The current appetite was NPO. Fluid intake was IV intake only. Incontinent of bowel and bladder. He is a DNR.  Pt has no movement on the left side and abnormal Extention to the Rt side. Weakness to all extremities and unable to swallow. pt was admitted to hospices.

Nursing Diagnosis :

Risk for impaired skin integrity R/T  -----------------

Subjective:

Objective:

Assessment :

Patient-centered goals:

Nursing interventions: Long and short term

Rationale:

Evaluations :

Answer 1

Stroke Nursing Care Plan

Subjective Data:

• Numbness
• Tingling
• Decreased sensation
• Difficulty swallowing
• Headache
• Pain
• Nausea
• Dizziness

Objective Data:

• Hemiparesis
• Hemiplegia
• Ataxia
• Dysmetria
• Facial droop
• Paralysis
• Aphasia
• Dysphagia
• Dysarthria
• Vomiting
• Increased secretions
• Incontinence
• LOC changes
• Nursing Diagnosis
• Risk for impaired skin integrity related to hemiparesis or hemiplegia and decreased mobility

Nursing Management

After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits.

Nursing Assessment

During the acute phase, a neurologic flow sheet is maintained to provide data about the following important measures of the patient’s clinical status:

• Change in level of consciousness or responsiveness.
• Presence or absence of voluntary or involuntary movements of extremities.
• Stiffness or flaccidity of the neck.
• Eye opening, comparative size of pupils, and pupillary reaction to light.
• Color of the face and extremities; temperature and moisture of the skin.
• Ability to speak.
• Presence of bleeding.
• Maintenance of blood pressure.

During the postacute phase, assess the following functions:

• Mental status (memory, attention span, perception, orientation, affect, speech/language).
• Sensation and perception (usually the patient has decreased awareness of pain and temperature).
• Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function.
• Continue focusing nursing assessment on impairment of function in patient’s daily activities.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses for a patient with stroke may include the following:

• Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury.
• Acute pain related to hemiplegia and disuse.
• Deficient self-care related to stroke sequelae.
• Disturbed sensory perception related to altered sensory reception, transmission, and/or integration.
• Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating.
• Disturbed thought processes related to brain damage.
• Impaired verbal communication related to brain damage.
• Risk for impaired skin integrity related to hemiparesis or hemiplegia and decreased mobility.
• Interrupted family processes related to catastrophic illness and caregiving burdens.
• Sexual dysfunction related to neurologic deficits or fear of failure.

Nursing Care Planning & Goals

The major nursing care planning goals for the patient and family may include:

• Improve mobility.
• Avoidance of shoulder pain.
• Achievement of self-care.
• Relief of sensory and perceptual deprivation.
• Prevention of aspiration.
• Continence of bowel and bladder.
• Improved thought processes.
• Achieving a form of communication.
• Maintaining skin integrity.
• Restore family functioning.
• Improve sexual function.
• Absence of complications.

Nursing Interventions

Nursing care has a significant impact on the patient’s recovery. In summary, here are some nursing interventions for patients with stroke:

• Positioning. Position to prevent contractures, relieve pressure, attain good body alignment, and prevent compressive neuropathies.
• Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
• Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
• Prevent edema. Elevate affected arm to prevent edema and fibrosis.
• Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
• Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
• Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and begin walking as soon as standing balance is achieved.
• Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.
• Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual perception is intact.
• Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in teaching alternate swallowing techniques.
• Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
• Be consistent in patient’s activities. Be consistent in the schedule, routines, and repetitions; a written schedule, checklists, and audiotapes may help with memory and concentration, and a communication board may be used.
• Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.

Improving Mobility and Preventing Deformities

• Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies.
• Apply a splint at night to prevent flexion of affected extremity.
• Prevent adduction of the affected shoulder with a pillow placed in the axilla.
• Elevate affected arm to prevent edema and fibrosis.
• Position fingers so that they are barely flexed; place hand in slight supination. If upper extremity spasticity is noted, do not use a hand roll; dorsal wrist splint may be used.
• Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day.

Establishing an Exercise Program

• Provide full range of motion four or five times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. If tightness occurs in any area, perform a range of motion exercises more frequently.
• Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
• Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (e.g., shortness of breath, chest pain, cyanosis, and increasing pulse rate).
• Supervise and support the patient during exercises; plan frequent short periods of exercise, not longer periods; encourage the patient to exercise unaffected side at intervals throughout the day.

Preparing for Ambulation

• Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is gone, when indicated).
• Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt table if needed).
• Begin walking as soon as standing balance is achieved (use parallel bars and have a wheelchair available in anticipation of possible dizziness).
• Keep training periods for ambulation short and frequent.

Preventing Shoulder Pain

• Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder.
• Use proper patient movement and positioning (e.g., flaccid arm on a table or pillows when patient is seated, use of sling when ambulating).
• Range of motion exercises are beneficial, but avoid over strenuous arm movements.
• Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as indicated.

Enhancing Self Care

• Encourage personal hygiene activities as soon as the patient can sit up; select suitable self-care activities that can be carried out with one hand.
• Help patient to set realistic goals; add a new task daily.
• As a first step, encourage patient to carry out all self-care activities on the unaffected side.
• Make sure patient does not neglect affected side; provide assistive devices as indicated.
• Improve morale by making sure patient is fully dressed during ambulatory activities.
• Assist with dressing activities (e.g., clothing with Velcro closures; put garment on the affected side first); keep environment uncluttered and organized.
• Provide emotional support and encouragement to prevent fatigue and discouragement.

Managing Sensory-Perceptual Difficulties

• Approach patient with a decreased field of vision on the side where visual perception is intact; place all visual stimuli on this side.
• Teach patient to turn and look in the direction of the defective visual field to compensate for the loss; make eye contact with patient, and draw attention to affected side.
• Increase natural or artificial lighting in the room; provide eyeglasses to improve vision.
• Remind patient with hemianopsia of the other side of the body; place extremities so that patient can see them.

Assisting with Nutrition

• Observe patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
• Consult with speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing techniques, advise patient to take smaller boluses of food, and inform patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated.
• Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
• Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensure that cuff of tracheostomy tube is inflated (if applicable); monitor and report excessive retained or residual feeding.

Attaining Bowel and Bladder Control

• Perform intermittent sterile catheterization during the period of loss of sphincter control.
• Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
• Assist the male patient to an upright posture for voiding.
• Provide highfiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated.
• Establish a regular time (after breakfast) for toileting.

Improving Thought Processes

• Reinforce structured training program using cognitive, perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses.
• Support patient: Observe performance and progress, give positive feedback, convey an attitude of confidence and hopefulness; provide other interventions as used for improving cognitive function after a head injury.

Improving Communication

• Reinforce the individually tailored program.
• Jointly establish goals, with the patient taking an active part.
• Make the atmosphere conducive to communication, remaining sensitive to patient’s reactions and needs and responding to them in an appropriate manner; treat the patient as an adult.
• Provide strong emotional support and understanding to allay anxiety; avoid completing patient’s sentences.
• Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may help with memory and concentration; a communication board may be used.
• Maintain patient’s attention when talking with the patient, speak slowly, and give one instruction at a time; allow the patient time to process.
• Talk to aphasic patients when providing care activities to provide social contact.

Maintaining Skin Integrity

• Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
• Employ pressure relieving devices; continue regular turning and positioning (every 2 hours minimally); minimize shear and friction when positioning.
• Keep skin clean and dry, gently massage the healthy dry skin and maintain adequate nutrition.

Improving Family Coping

• Provide counseling and support to the family.
• Involve others in patient’s care; teach stress management techniques and maintenance of personal health for family coping.
• Give family information about the expected outcome of the stroke, and counsel them to avoid doing things for the patient that he or she can do.
• Develop attainable goals for the patient at home by involving the total health care team, patient, and family.
• Encourage everyone to approach the patient with a supportive and optimistic attitude, focusing on abilities that remain; explain to the family that emotional lability usually improves with time.

Helping the Patient Cope with Sexual Dysfunction

• Perform indepth assessment to determine sexual history before and after the stroke.
• Interventions for patient and partner focus on providing relevant information, education, reassurance, adjustment
• of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a means of sexual expression and satisfaction.

Teaching points

• Teach patient to resume as much self care as possible; provide assistive devices as indicated.
• Have occupational therapist make a home assessment and recommendations to help the patient become more independent.
• Coordinate care provided by numerous health care professionals; help family plan aspects of care.
• Advise family that patient may tire easily, become irritable and upset by small events, and show less interest in daily events.
• Make a referral for home speech therapy. Encourage family involvement. Provide family with practical instructions to help patient between speech therapy sessions.
• Discuss patient’s depression with the physician for possible antidepressant therapy.
• Encourage patient to attend community-based stroke clubs to give a feeling of belonging and fellowship to others.
• Encourage patient to continue with hobbies, recreational and leisure interests, and contact with friends to prevent social isolation.
• Encourage family to support patient and give positive reinforcement.
• Remind spouse and family to attend to personal health and wellbeing.

Evaluation

Expected patient outcomes may include the following:

• Improved mobility.
• Absence of shoulder pain.
• Self-care achieved.
• Relief of sensory and perceptual deprivation.
• Prevention of aspiration.
• Continence of bowel and bladder.
• Improved thought processes.
• Achieved a form of communication.
• Maintained skin integrity.
• Restored family functioning.
• Improved sexual function.
• Absence of complications.

Discharge and Home Care Guidelines

Patient and family education is a fundamental component of rehabilitation.

• Consult an occupational therapist. An occupational therapist may be helpful in assessing the home environment and recommending modifications to help the patient become more independent.
• Physical therapy. A program of physical therapy may be beneficial, whether it takes place in the home or in an outpatient program.
• Antidepressant therapy. Depression is a common and serious problem in the patient who has had a stroke.
• Support groups. Community-based stroke support groups may allow the patient and the family to learn from others with similar problems and to share their experiences.
• Assess caregivers. Nurses should assess caregivers for signs of depression, as depression is also common among caregivers of stroke survivors.