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.