Which action should take the highest priority when caring for a client with hemiparesis
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Priority Nursing Interventions Caring for the Stroke PatientMary P Amatangelo et al. Crit Care Nurs Clin North Am. 2020 Mar. AbstractNearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. A collaborative interdisciplinary team approach best facilitates the ICU care of an acute stroke patient. Keywords: Complex ischemic stroke patients; Intensive care unit (ICU) nursing care; Poststroke complications. Copyright © 2019 Elsevier Inc. All rights reserved. Conflict of interest statementDisclosure The authors have nothing to disclose. Similar articles
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Learn about the nursing care management of patients with cerebrovascular accident in this nursing study guide.
What is Cerebrovascular Accident?A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain.
ClassificationStrokes can be divided into two classifications.
Risk FactorsThe following are the nonmodifiable and modifiable risk factors of Cerebrovascular accident: Nonmodifiable
Modifiable
PathophysiologyThe disruption in the blood flow initiates a complex series of cellular metabolic events. Cerebrovascular accident (CVA)
Statistics and EpidemiologyStroke is a worldwide phenomenon suffered through all walks of life.
CausesStrokes are caused by the following:
Clinical ManifestationsStroke can cause a wide variety of neurologic deficits, depending on the location of the lesion, the size of the area of inadequate perfusion, and the amount of the collateral blood flow. General signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of the body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache. Recognizing Stroke: BEFASTGeneral signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of the body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache.
Motor Loss
Communication Loss
Perceptual Disturbances and Sensory Loss
Impaired Cognitive and Psychological Effects
PreventionPrimary prevention of stroke remains the best approach. Prevention of stroke.
ComplicationsIf cerebral oxygenation is still inadequate; complications may occur.
Assessment and Diagnostic FindingsAny patient with neurologic deficits needs a careful history and complete physical and neurologic examination.
Medical ManagementPatients who have experienced TIA or stroke should have medical management for secondary prevention.
Surgical ManagementSurgical management may include prevention and relief from increased ICP.
Nursing ManagementAfter the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits. Nursing AssessmentDuring the acute phase, a neurologic flow sheet is maintained to provide data about the following important measures of the patient’s clinical status:
During the postacute phase, assess the following functions:
Nursing DiagnosisBased on the assessment data, the major nursing diagnoses for a patient with stroke may include the following:
Nursing Care Planning & GoalsMain article: Cerebrovascular Accident (Stroke) Nursing Care Plans The major nursing care planning goals for the patient and family may include:
Nursing InterventionsNursing care has a significant impact on the patient’s recovery. In summary, here are some nursing interventions for patients with stroke:
Improving Mobility and Preventing Deformities
Establishing an Exercise Program
Preparing for Ambulation
Preventing Shoulder Pain
Enhancing Self Care
Managing Sensory-Perceptual Difficulties
Assisting with Nutrition
Attaining Bowel and Bladder Control
Improving Thought Processes
Improving Communication
Maintaining Skin Integrity
Improving Family Coping
Helping the Patient Cope with Sexual Dysfunction
Teaching points
EvaluationExpected patient outcomes may include the following:
Discharge and Home Care GuidelinesPatient and family education is a fundamental component of rehabilitation.
Documentation GuidelinesThe focus of documentation should involve:
Practice Quiz: Cerebrovascular Accident (Stroke)Here’s a 5-item practice quiz for this Cerebrovascular Accident (Stroke) Study Guide. Please visit our nursing test bank for more NCLEX practice questions. 1. As a cause of death in the United States, stroke currently ranks: A. Second 2. The most common cause of cerebrovascular accident is: A. Arteriosclerosis 3. The degree of neurologic damage that occurs with an ischemic stroke depends on the: A. Location of the lesion. 4. The most common side effect of tPA is: A. An allergic reaction. 5. The majority of strokes have what type of origin? A. Cardiogenic emboli. Answers and Rationale 1. Answer: B. Third
2. Answer: A. Arteriosclerosis
3. Answer: D. Combination of the above factors.
4. Answer: B. Bleeding.
5. Answer: D. Small artery thrombotic.
See AlsoPosts related to Cerebrovascular Accident (Stroke):
[sc name=”Affiliate_MedicalSurgical”] Which of the following is most likely associated with a cerebrovascular accident?The major risk factors include: High blood pressure. This is the primary risk factor for a stroke.
What does CVA mean in medical terms?A stroke, also referred to as a cerebral vascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain. When the cells in the brain are deprived of oxygen, they die.
What is the major cause of cerebrovascular accidents?In medicine, a loss of blood flow to part of the brain, which damages brain tissue. Cerebrovascular accidents are caused by blood clots and broken blood vessels in the brain.
Which of the following terms related to aphasia refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?Apraxia is inability to execute purposeful, previously learned motor tasks, despite physical ability and willingness, as a result of brain damage.
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