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neuro #2

Terms in this set (63)

interventions for aphasia
1. provide repetitive directions
2. break tasks down to one step at a time
3. repeat names of objects frequently used
4. allow time for the client to communicate
5. use a picture board, communication board, or computerized technologies
NCLEX 813
-many stroke patients have speech problems, including dysarthria and aphasia
-a speech pathologist evaluates and treats the patient with language disorders
-the patient may be frustrated and should be approached in an unhurried manner
-often the patient does much better with communication when no feeling pressured to speak
-giving the patient a communication board may be helpful
-wait for the patient to communicate, rather than prompting or finishing the sentence before the patient has a chance to find the appropriate word
-inability to articulate does not mean that the patient has decreased cognitive abilities
impaired verbal communication r/t ischemic injury
-speak slowly and distinctly
-ask questions that can be answered by yes or no (or signals)
-try to anticipate patient needs
-provide a call signal within reach of the unaffected hand
-begin speech therapy as soon as possible
imbalanced nutrition: less than body requirements r/t impaired ability to swallow
-provide IV fluids and tube feedings as prescribed during the initial period
-refer to speech therapist for assessment of swallowing problems
-assess ability to swallow before initiating feedings
-position patient with head elevated and turned to unaffected side during feedings
-provide foods initially that are easier to swallow (soft foods, except for mashed potatoes)
-thin liquids are often difficult to swallow and may promote coughing; thicken liquids with a commercially available thickening agent (Thick-It)
-do not use milk products because they tend to increase the viscosity of mucus and increase salivation
-use a training cup for fluids as necessary
-do not use a straw
-inspect mouth for food trapped in cheek pockets
-be patient when feeding patient and provide directions for swallowing as needed; ensure that meals are uncrushed and non stressful
-encourage patient to feed self as soon as possible; provide self-help devices as necessary
-provide scrupulous oral hygiene after meal because food may collect on the affected side of the mouth
AHN 699
respiratory system
1. monitor respiratory status because paralysis of the intercostal and abdominal muscles occurs with C4 injuries
2. monitor arterial blood gases and maintain mechanical ventilation if prescribed to prevent respiratory arrest, especially with cervical injuries
3. encourage deep breathing and the use of an incentive spirometer
4. monitor for signs of infection, particularly pneumonia
cardiovascular system
1. monitor for cardiac dysrhythmias
2. monitor for signs of hemorrhage or bleeding around the fracture site
3. monitor for signs of shock, such as hypotension, tachycardia, and a weak and thready pulse
4. monitor the lower extremities for DVT
5. measure circumferences of the calf and thigh to identify increases in size
6. apply thigh-high antiembolism stockings or sequential compression devices (SCDs) as prescribed
7. remove antiembolism stockings and SCDs daily to assess the skin
8. monitor for orthostatic hypotension when repositioning the client
neuromuscular system
1. monitor neurological status
2. monitor motor and sensory status to determine the level of injury
3. monitor motor ability by testing the client's ability to squeeze hands, spread the fingers, move the toes, and turn the feet
4. check for absent sensation, hypo sensation, or hyper sensation by pinching the skin or pricking it with a pin, starting at the toes and working upward
5. monitor for signs of autonomic dysreflexia and spinal shock
6. immobilize the client to promote healing and prevent further injury
7. monitor pain
8. initiate measures to reduce pain
9. administer analgesics as prescribed
10. monitor for complications of immobility
11. prepare the client for decompression laminectomy, spinal fusion, or insertion of instrumentation or rods if prescribed
12. collaborate with the physical therapist and occupational therapist to determine appropriate exercise techniques, assess the need for hand and wrist splints, and develop and appropriate plan to prevent foot drop
GI system
1. check abdomen for distention and hemorrhage
2. monitor bowel sounds and assess for paralytic ileus
3. prevent bowel retention
4. initiate a bowel control program as appropriate
5. maintain adequate nutrition and a high-fiber diet
renal system
1. prevent urinary retention
2. initiate a bladder control program as appropriate
3. maintain fluid and electrolyte balance
4. maintain adequate fluid intake of 2000 mL/day
5. monitor for UTI and calculi
integumentary system
1. check skin integrity
2. turn the client every 2 hours
psychosocial integrity
1. monitor psychosocial status
2. encourage the client to express feelings of anger and depression
3. discuss the sexual concerns of the client
4. promote self-care, setting realistic goals based on the client's potential functional level
5. encourage contact with appropriate community resources
NCLEX 807