Terms in this set (14)

During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems, including atelectasis, airway obstruction, and aspiration pneumonia.
The patient's neurologic status must be monitored closely to detect changes suggesting extension of the stroke, increased ICP, vasospasm, or recovery from stroke symptoms.
Nursing goals for the cardiovascular system are aimed at maintaining homeostasis; the nurse must perform a thorough cardiac assessment, manage infusions, and monitor fluid balance. Measures to prevent deep venous thrombosis (DVT) are often implemented.
To maintain optimal function of the musculoskeletal system, measures are used to prevent joint contractures and muscular atrophy.
The skin of the patient with stroke is particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility.
The most common bowel problem for the patient who has experienced a stroke is constipation. Patients may be prophylactically placed on stool softeners and/or fiber.
The primary urinary problem is poor bladder control, resulting in incontinence. Efforts should be made to promote normal bladder function and to avoid the use of indwelling catheters.
The patient may initially receive IV infusions to maintain fluid and electrolyte balance, as well as for administration of drugs. Patients with severe impairment may require enteral or parenteral nutrition support. Swallowing ability will need to be assessed.
Assess the patient both for the ability to speak and the ability to understand and support the patient accordingly.
Homonymous hemianopsia (blindness in the same half of each visual field) is a common problem after a stroke. Persistent disregard of objects in part of the visual field should alert you to this possibility.
A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. Use nursing interventions designed to facilitate coping by providing information and emotional support.
The patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility.
Regardless of the care setting, ongoing rehabilitation is essential to maximize the patient's abilities. Rehabilitation requires a team approach so the patient and family can benefit from the combined, expert care of a stroke team.
The goals for rehabilitation of the patient with stroke are mutually set by the patient, family, nurse, and other members of the rehabilitation team.
Initially you emphasize the musculoskeletal functions of eating, toileting, and walking for the rehabilitation of the patient. Interventions advance in a manner of progressive activity.
After the acute phase, a dietitian can assist in determining the appropriate daily caloric intake based on the patient's size, weight, and activity level. The diet must also be adjusted for the ability of the patient to swallow solids and fluids.
A bowel management program is implemented for problems with bowel control, constipation, or incontinence. Nursing measures are also focused on promoting urinary continence.
Patients who have had a stroke frequently have perceptual deficits. For example, patients with a stroke on the right side of the brain usually have difficulty in judging position, distance, and rate of movement.
The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. As a nurse, you should help patients and families cope with these losses.
Speech, comprehension, and language deficits are the most difficult problems for the patient and family. Speech therapists can assess and formulate a plan of care to support communication.