Nursing care of patients with Stroke

                                                STROKE OR CEREBROVASCULAR ACCIDENT IS AN EMERGENCY CONDITION WHERE THE PATIENT SUFFERS A SUDDEN ATTACK OF VARIOUS NEUROLOGICAL SIGNS AND SYMPTOMS DUE TO A STATE OF CEREBRAL INFARCTION. THE NURSING CARE WITH NURSING DIAGNOSIS IS DISCUSSED BELOW.

                                  ONGOING ASSESSMENT OF ALL BODY SYSTEMS IS ESSENTIAL. THE USE OF A STANDERDIZED NEUROLOGIC ASSESSMENT TOOL SUCH AS GCS ASSISTS THE NURSE IN DOCUMENTING CHANGES IN CLIENT STATUS AND IN MONITORING CLIENT PROGRESS.

NURSING DIAGNOSIS AND MANAGEMENT:

1.      INEFFECTIVE TISSUE PERFUSION (CEREBRAL) RELATED TO BLOCK IN THE BLOOD FLOW TO A PART OF THE BRAIN.

INTERVENTIONS:

·         ASSESS THE CLIENT’S CONDITION. ASSESS FOR THE DETERIORATING SYMPTOMS NEUROLOGICALLY AND NOTIFY THE PHYSICIAN.

·         MAINTAIN THE CLIENT’S BP.

·         MAINTAIN THE CLIENT’S TEMPERATURE.

·         ELAVATE THE HEAD END TO 30 DEGREES TR REDUCE CEREBRAL EDEMA.

·         DRUGS LIKE MANNITOL, ANTIHYPERTENSIVES SHOULD BE PRESCRIBED.

·         MILD LAXATIVES AND STOOL SOFTNERS ARE PRESCRIBED.

2.      RISK FOR PROLONGED BLEEDING RELATED TO USE OF THROMBOLYTIC AGENTS:

INTERVENTIONS:

·         NO ARTERIAL PUNCTURES SHOULD BE PERFORMED UNTIL 24 HRS OF THROMBOLYTIC THERAPY.

·         THE NURSE SHOULD MONITOR FOR ALREADY PUNCTURED SITES FOR ANY SIGNS OF BLEEDING.

·         CHECK FOR BLEEDING IN THE NOSTRILS, EAR CANAL, MOUTH.

·         PRESSURE SHOUL BE APPLIED FOR COMPRESSIBLE BLEEDING SITES.

·         COMPLETE BED REST SHOULD BE ADVISED TO THE PATIENT.

·         REPORT ANY MANIFESTATIONS OF BLEEDING TO THE PHYSICIAN IMMEDIATELY.

3.      IMPAIRED PHYSICAL MOBILITY RELATED TO HEMIPLEGIC CONDITION OF THE CLIENT.

·         ENCOURAGE BED EXERCISES FOR THE PATIENT- BOTH ACTIVE AND PASSIVE.

·         HELP THE CLIENT SIT UP ON THE BED. INITIALLY THE NURSE SHOULD SUPPORT THE BACK AND THE HEAD OF THE CLIENT AS THERE IS A CHANCE OF LOSS OF BALANCE.

·         ONCE THE CLIENT IS ABLE TO SIT UP INDEPENDENTLY, SUPPORT HIM TO SIT ON THE EDGE OF THE BED WITH HIS LEGS DOWN.

·         WHILE PERFORMING THIS THE NURSE SHOULD EXTEND THE WEAK OR PARALYZED LIMBS AND SHOULD ALSO ENCOURAGE THE PATIENT TO DO SO.

·         SLOWLY SUPPORT THE CLIENT TO STAND UP AND SIT ON A CHAIR. THE WEAK SIDE SHOULD BE SUPPORTED WITH PILLOWS WHILE SITTING ON THE CHAIR.

·         PROMOTE WALKING. THE NURSE SHOULD POSITIOIN HERSELF ON THE WEAKER SIDE AND SUPPORT THE PATIENT TO STAND UP. A CANE OR A WALKING STICK CAN BE GIVEN ON THE UNAFFECTED SIDE.

4.      RISK FOR HYPERTHERMIA RELATED TO BLEEEDING OR EDEMA OF THE HYPOTHALAMUS.

·         TREAT FEVER WITH ANTIPYRETICS.

·         A COLD SPONGE OR TEPID SPONGING CAN BE PROVIDED.

·         SHIVERING SHOULD BE PREVENTED BY PROVIDING A BLANKET. SHIVERING INCREASES THE BODY TEMPERATURE.

5.      RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO PROLONGED BED REST.

·         CLIENT’S SKIN MUST BE INSPECTED FOR AREAS OF REDNESS OR SORES.

·         PROPER BACK CARE AND MASSAGE SHOULD BE PROVIDED.

·         POSITION OF THE CLIENT SHOULD BE CHANGED EVERY 2 HRS USING APPROPRIATE COMFORT DEVICES.

·         SUPPORT THE AFFECTED ARM AND LEG WHILE CHANGING THE POSITION OF THE CLIENT.

·         DO NOT POSITION THE PATIENT ON THE AFFECTED SIDE FOR MORE THAN 20 TO 30 MINS AS IT MAY CAUSE PAIN AND DISCOMFORT.

6.      RISK FOR CONTRACTURE RELATED TO PARALYSIS OF THE LIMBS.

·         ASSESS FOR ROM OF ALL THE JOINTS.

·         PERFORM PASSIVE EXERCISES.

·         MAINTAIN THE LIMBS IN ALIGNMENT.

·         PROVIDE A FOOT BOARD TO PREVENT FOOT DROP.

·         A TROCHANTER ROLL CAN BE USED ALONGSIDE THE THIGH TO PREVENT EXTERNAL HIP ROTATION.

·         ONCE SOME VOLUNTARY MOVEMENTS RETURNS, ENCORAGE THE CLIENT WITH ASSISTED MOVEMENTS.

·         DO NOT PLACE A PILLOW UNDER THE AFFECTED KNEE AS IT PROMOTES FLEXION OF THE JOINT.

·         ASSIST THE CLIENT SIT ON THE CHAIR AS EXPLAINED EARLIER. HIUS FEET SHOULD BE FLAT ON THE GROUND.

·         PLACE THE AFFECTED HAND IN A POSITION OF FUNHCTION i.e., SLIGHTLY SUPINATED WITH FINGERS SLIGHTLY FLEXED. PREVENT ADDUCTION OF THE AFFECTED HAND BY PLACING A PILLOW IN THE AXILLA.

·         THE ARM MAY BE SUPPORTED ON A PILLOW.

7.      IMBALANCED NUTRITION, LESS THAN BODY REQUIREMENT RELATED TO INABILITY TO SWALLOW.

·         FEEEDING A DYPHAGIC CLIENT NEEDS PATIENCE AND SKILL.

·         PROMOTE HEAD CONTROL: FEDING SHOULD BE DONE FROM THE MIDLINE AND NOT FROM THE SIDE. HEAD CAN BE SUPPORTED WITH A PILLOW OR BY PLACING A HAND ON THE FOREHEAD.

·         ASSIST IN POSITIONING: HAVE THE CLIENT IN AN UPRIGHT POSITION AS CLOSE TO 90 DEGREES AS POSSIBLE.

·         PROMOTE MOUTH OPENING: IF THE CLIENT DOES NOT OPEN THE MOUTH, LIGHTLY TOUCH BOTH THE LIPS WITH THE TIP OF THE FINGERS. APPLY LIGHT PRESSURE TO THE CHIN JUST BELOW THE LOWER LIP.

·         STIMULATE MOUTH CLOSING: STIMULATE LIP CLOSURE WITH GENTLY STROKING THE LIPS WITH FINGERS OR APPLYING GENTLE PRESSURE ABOVE THE UPPER LIP WITH THE THUMB.

·         HELP THE CLIENT IN SWALLOWING: FEED THE CLIENT SLOWLY AND OFFER SMALL AMOUNTS AT A TIME. BEGIN WITH FOODS THAT REQUIRE NO CHEWING OR EASY TO SWALLOW. GRADUALLY PROGRESS TO SEMISOLID TO SOLID FOODS. PLACE THE FOOD IN THE UNAFFECTED SIDE OF THE MOUTH BUT FROM THE MIDLINE AND ENCOURAGE THE PATIENT TO CHEW. TEACH THE PATIENT TO SWEEP OUT THE FOOD REMAINED IN THE AFFECTED SIDE WITH THE USE OF THE TONGUE.

Alzhiemer's disease and nursing care

ALZHEIMER’S DISEASE.

                   ALZHIEMER’S DISEASE IS THE MOST COMMON TYPE OF DEMENTIA AMONG OLDER ADULTS. THE TERM DEMENTIA REFERS TO THE LOSS OF MEMORY, REASONING, JUDGEMENT AND LANGUAGE TO SUCH AN EXTENT THAT IT INTERFERES WITH EVERYDAY LIFE.

                   COGNITION REFERS TO THE ACT OF OR PROCESS OF THINKING, PERCIEVING AND LEARNING. DEMENTIA IS THE DISORDER OF COGNITION. IN DEMENTIA COGNITIVE ACTIVITIES LIKE DECISION MAKING, JUDGEMENT, MEMORY, SPATIAL ORIENTATION, THINKING, REASONING AND VERBAL COMMUNICATION GETS IMPAIRED. THE PERSON ALSO EXPERIENCES BEHAVIOURAL CHANGES AND PERSONALITY CHANGES DEPENDING ON THE AREAS OF THE BRAIN AFFECTED.

ETIOLOGY AND RISK FACTORS:

·         THE EXACT CAUSE IS UNKNOWN.

          THE RISK FACTORS MAY BE,

·         INCREASING AGE.

·         GENETIC FACTORS.

·         INFLAMMATION.

·         STROKE.

·         OXIDATIVE DAMAGE.

PATHOPHYSIOLOGY:

        IN ALZHEIMER’S DISEASE THE CHANGES SEEN THE BRAIN ARE DEVELOPMENT OF BETA AMYLOID PLAQUES AROUND THE NERVE FIBRES AND NEURUFIBRILLARY TANGLES.

BETA AMYLOID IS A PROTIEN SUBSTANCE. IT IS A PRODUCT OF DEGENERATING NERVE FIBRES. IN ALZHEIMER’S DISEASE THE NERVE FIBRES UNDERGO DEGENERATIVE CHANGES LEADING TO FORMATION AND ACCUMULATION OF THEIS PROTIEN AROUND THE NERVE FIBRES AND ALSO CAUSING NERVE FIBRE TANGLES.

PATIENTS SUFFERING FROM ALZHIEMER’S ALSO SHOW THE DECREAS IN THE NEUROTRANSMITTER ACETYLCHOLINE.

THE DEVELOPMENT OF PLAQUES IS FIRST SEEN ON THE HIPPOCAMPUS, THE AREA OF THE BRAIN WHICH STORES MEMORY. THUS THE INITIAL SYMPTOMS OF ALZHEIMER’S DISEASE IS MEMORY IMPAIRMENT.

CLINICAL MANIFESTATIONS:

·         MEMORY DISTURBANCE

·         POOR JUDGEMENT AND PROBLEM SOLVING SKILLS

·         CONFUSION EVEN IN DAILY ACTIVITIES AND PATIEMT USUALLY FORGETS WHERE HE IS AND WHAT HE IS DOING.

·         THE PATIENT BECOMES IRRITABLE, SUSPICIOUS OR INDIFFERENT.

·         AGITATION.

·         LANGUAGE DISTURBANCE.

·         PARAPHASIAS (WORDS USED IN WRONG CONTEXT)

·         PALILALIA – REPEATING WORDS OR PHRASES JUST SPOKEN BY HIMSELF.

·         ECHOLALIA-REPEATING WORDS OR PHRASES SPOKEN BY OTHERS.

·         APRAXIA

·         HYPERORALITY- DESIRE TO TAKE EVERYTHING INTO MOUTH TO CHEW OR TASTE.

·         DIFFICULTY IN SWALLOWING.

·         DEPRESSION.

·         PERSON FEARS PERSONAL HARM, THEFT OF PROPERTY OR INFEDILITY OF THE SPOUSE.

·         DELUSIONS

·         WANDERING AT NIGHT.

·         FAILURE TO RECOGNIZE FAMILY AND FRIENDS AND TOTAL CESSATION OF COMMUNICATION.

·         MINIMAL VOLUNTARY MOVEMENT AND RIGIDITY OF LIMBS.

·         URINARY AND FECAL INCONTINENCE.

·         ASPIRATION.

DIAGNOSTIC EVALUATION:

·         THERE IS NO DEFINITIVE TEST FOR ALZHEIMER’S DISEASE. THE DIAGNOSIS IS MADE BY OBSERVATION OF SIGNS AND SYMPTOMS AND AN EXAMINATION OF THE COGNITIVE FUNCTION.

·         COMPUTED TOMOGRAPHY

·         MRI.

·         POSITRON EMISSION TOMOGRAPHY.

MEDICAL MANAGEMENT:

SEVERAL MEDICATIONS ARE AVAILABLE TO CONTROL THE SYMPTOMS OF ALZHEIMER’S DISEASE ALTHOUGH THERE IS NO CURE FOR IT.

DONEPEZIL, TACRINE TO RETAIN ACETYLCHOLINE.

VITAMIN E IS PROVED TO BE EFFECTIVE IN DELAYING THE DEVELOPMENT OF ALZHEIMER’S DISEASE.

NURSING MANAGEMENT:

1.      IMPAIRED VERBAL COMMUNICATION RELATED TO NEURONAL DEGENERATION.

·         DECREASE THE ENVIRONMENTAL STIMULI.

·         APPROACH THE CLIENT CALMLY AND WITH ASSURANCE.

·         DO NOT PLACE ANY DEMANDS IN FRONT OF THE PATIENT.

·         GENTLY DISTRACT THE PATIENT FROM THE TOPIC IF HE STARTS GETTING AGITATED OR DEPRESSED.

·         USE MULTIPLE SENSORY MODALITIES.

2.      DISTURBED THOUGHT PROCESS RELATED TO NEURONAL DEGENERATION.

·         APPLY INTERVENTIONS TO ENHANCE MEMORY.

·         REORIENT THE CLIENT AS PER NECESSITY.

·         REPETATION IS USEFUL FOR RETAINING THE MEMORY.

3.      RISK FOR INJURY RELATED TO FORGETFULNESS, IMPAIRED JUDGEMENT AND MOTOR IMPAIRMENTS.

·         ENSURE THE CLIENTS CANNOT LEAVE THE PREMISES WITHOUT BEING NOTICED.

·         THE CLIENT SHOULD AN IDENTIFICATION BADGE.

·         CLIENT SHOULD NOT BE ALLOWED TO DO DANGEROUS ACTIVITIES LIKE COOKING, DRIVING WITHOUT SUPERVISION.

4.      SELF CARE DEFICIT RELATED TO LOSS OF MEMORY.

·         AS FAR AS POSSIBLE PROMOTR INDEPENDENCE FOR CLIENT’S SELF CARE ACTIVITIES AS IT WILL PROMOTE HIS CONFIDENCE.

·         GIVE THE CLIENT ENOUGH TIME TO COMPLETE THE TASK.

·         CONSTANTLY REMINDING AND ENCOURAGING IS ALSO REQUIRED.

·         CLIENT MAY REQUIRE SOME ASSISTANCE WHICH SHOULD BE GIVEN TO THE CLIENT.

5.      URINARY INCONTINENCE RELATED TO NEURONAL DEGENERATION.

·         SCHEDULED VOIDING AND DEFECATION TIME.

·         FLUID INTAKE AFTER DINNER CAN BE RESTRICTED.

·         THE CLIENT MAY FORGET WHERE THE TOILET OR BATHROOM IS. HE MAY REQUIRE ASSISTANCE.

Nursing care for a patient with craniotomy

CRANIOTOMY

               THE TERM CRANIOTOMY MEANS TO SURGICALLY CREATE AN OPENING INTO THE SKULL FOR VARIOUS TYPES OF SURGICAL PROCEDURES ON THE BRAIN.

NURSING MANAGEMENT OF THE PATIENT AFTER A CRANIOTOMY.

1.      RISK FOR INEFFECTIVE TISSUE PERFUSION, CEREBRL RELATED TO CEREBRAL EDEMA OR BEEDING AFTER CRANIOTOMY.

·         ASSESS THE NEUROLOGIC STATUS AND VITAL SIGNS FREQUENTLY.

·         ELAVATE HEAD END OF THE BED TO 30 DEGREES.

·         MAINTAIN HAED AND NECK IN NEUTRAL ALIGNMENT.

·         CHANGE THE POSITION SLOWLY WOTH PROPER SUPPORT TO THE HEAD AND NECK.

·         MANAGE BP EFFECTIVELY.

·         MONITOR INTAKE & OUTPUT CHART.

·         MONITOR PULSE OXIMETRY AND ARTERIAL BLOOD GAS.

·         SUCTION AIRWAY AS NEEDED.

·         CONTINUOUS ASSESSMENT WITH GLASGOW COMA SCALE IS ALSO ESSENTIAL.

·         ADMINISTER CORTICOSTEROIDS AS PER ORDER.

·         ADMINISTER ANTI EPILEPTIC DRUGS AS ORDERED.

·         ADMINITER IV MANNITOL TO REDUCE INTRACRANIAL PRESSURE.

·         PROVIDE STOOL SOFTNERS TO AVOID STRAINING OF THE BOWEL.

2.      PAIN RELATED TO SURGICAL INCISION.

·         PROVIDE PAIN MEDICATIONS AS PER ORDER OF THE PHYSICIAN.

·         TREAT FOR CEREBRAL EDEMA AS MENTIONED ABOVE.

·         PROMOTE SLEEP AND PROPER BED REST.

3.      IMPAIRED PHYSICAL MOBILITY RELATED TO IMMOBILIZATION AFTER A SURGERY.

·         CHANGE POSITIONS FREQUENTLY BUT SUPPORT THE HEAD AND NECK WHILE DOING SO.

·         PROVIDE FOR PASSIVE ROM EXERCISES.

·         INSPECT THE SKIN FOR ANY REDNESS.

·         GIVE A BED BATH AND A BACK MASSAGE TO THE CLIENT.

·         PROVIDE A COMFORTABLE BED WITH WRINKLE FREE LINEN.

4.      INEFFECTIVE COPING RELATED TO FEAR OF CHANGES IN BODY IMAGE AND LIFE EXPECTANCY.

·         PROVIDE OPPORTUNITIES FOR EXPRESSION OF FEELINGS.

·         ENCOURAGE FAMILY MEMBERS TO ASSIST IN MEETING CLIENT’S NEEDS.

·         ENCOURAGE THE CLIENT WHEN HE COOPERATES.

·         ESTABLISH TRUST RELATIONSHIPS.

·         REDUCE ENVIRONMENTAL STRESS AND STIMULI.

5.      ANXIETY RELATED TO UNCERTAIN FUTURE AND PROGNOSIS.

·         PROVIDE PROPER KNOWLEDGE AND INFORMATION TO THE CLIENT ABOUT HIS CONDITION.

·         ENCOURAGE OPEN COMMUNICATION BETWEEN THE CLIENT, FAMILY MEMBERS AND HEALTH CARE TEAM PROFESSIONALS.

6.      RISK FOR DISTURBED THOUGHT PROCESS RELATED TO NEUROLOGICAL CHANGES FROM EDEMA OR SURGICAL EXICISIONS OF AREAS OF BRAIN.

·         INFORM FAMILY ABOUT THE REASONS FOR CHANGES IN BEHAVIOUR.

·         MAINTAIN A NON JUDGEMENTAL BEHAVIOUR

·         HAVE A CALM APPROACH TOWARDS THE CLIENT.

·         ALLOW THE CLIENT TO VERBALIZE CONCERNS.