CVA Nursing Process Flashcards
1
Q
Initial Assessments
A
- Assess orientation to Time, place, and name first!!!!!!!!!!
- Assess symmetry of the face - equal bilaterally? (facial droop) ask them to smile :D
- Assess for symptoms i.e. headache, dizziness, trouble with vision (unable to see clearly), impaired speech, numbness to mouth/face, right or left sided numbness/weakness.
- If the patient is having difficulties swallowing, you must tell the patient that he/she must not eat or drink since he/she may choke/aspirate and that swallowing must be examined by the doctor.
- Assess vital signs (act on abnormal findings)
- Auscultate lungs.
2
Q
PERRLA and Accomodation
A
- Observe the pupils for size. (3 to 5 millimeters) how big are they
- Reaction to light (cranial nerve III). Dim the lights, ask the patient to look into the distance, shine a bright penlight (approach laterally) into the pupil. Observe for direct response (same eye) and consensual response (opposite eye). Brisk or sluggish reaction?
- For accommodation, ask the patient to look in the distance and then at the tip of their nose. If the patient finds this difficult to do, have them follow their extended thumb as it is brought in towards the tip of their nose.
- Assess right and left hand grips for equal strength (cross fashion)
- Assess lower extremities for equal strength bilaterally (plantar flexion and dorsiflexion of both feet)
3
Q
Oxygenation
Ineffective airway clearance related to inability to bring up secretions
A
- Ensure airway is patent
- Monitor RR & O2 sat
- Provide adequate oxygenation
- Suctioning to clear airway
- Encourage DB&C to expel secretions
- Encourage use of incentive spirometer to prevent atelectasis and promote deep breathing
4
Q
Oxygenation: Cardiovascular
Altered tissue perfusion related to decreased cerebral blood flow
A
- Monitor neurological status q1hr initially to detect changes
- Provide adequate oxygenation
- Administer meds to increase tissue perfusion as per order i.e. vasopressin, calcium channel blockers, anticoagulants, thrombolytics
- Avoid neck flexion or extreme hip or knee flexion to prevent obstruction of arterial & venous blood flow
5
Q
Oxygenation: Neurovascular
Risk for peripheral neurovascular dysfunction related to decreased mobility (i.e. hemiparesis)
A
Monitor neurovascular system (the five Ps):
- Pain
- Pallor (color & temp)
- Pulses
- Paresthesia (abnormal sensations)
- Paralysis
Provide TED stockings (if ordered)
6
Q
Activity and Rest
- Impaired mobility related to hemiparesis
- Potential for fatigue
- Activity intolerance
- Self-care deficits
- Disuse syndrome
A
- Promote exercise as per client’s tolerance & readiness i.e. passive ROM
- Position changes as per protocol i.e. alignment, support pillows, splints
- Provide restful environment after periods of exercise
7
Q
Nutrition
- Risk for aspiration related to dysphagia
- Potential for inadequate nutritional intake related to hemiparesis
- Feeding self-care deficit related to hemiparesis
A
- Consult speech therapist, OT if inability to swallow or absent gag reflex
- Place in high Fowler’s for meals to prevent aspiration
- Cut food into small bits, thickened liquids
- Place food on unaffected side of mouth, monitor for food pocketing
- Provide assistive eating devices
- Monitor albumin, total protein, BMI
- Assistive devices for eating
8
Q
**Fluid and Electrolytes **
- Risk for fluid volume imbalance
- Fluid volume deficit/excess
- Potential for electrolyte imbalance
A
- Monitor for signs of fluid overload or dehydration
- Monitor In/Outs
- Adjust fluid intake to individual needs of patient
- Monitor electrolytes
9
Q
Elimination
- Altered pattern of urinary elimination
- Alteration in bowel elimination - risk for constipation
A
- Monitor I/O
- Promote normal bladder function i.e. adequate fluids during the day, schedule toileting, offer bedpan, commode, etc.
- Encourage fiber intake
- Assess need for stool softener
10
Q
Protection
Potential for impaired skin integrity related to loss of sensations, or hemiparesis, or immobility
A
- Provide pressure relief by position changes, special mattresses, or wheelchair cushions. Pillows can be used under lower extremities to reduce pressure on heels.
- Good skin hygiene
- Apply lotions to dry skin
- Braden scale
11
Q
Neurologic Function
- Altered LOC related to increased ICP
- Impaired memory related to apraxia
A
- Glasgow Coma Scale (GCS)
- Monitor neurological status i.e. PERRLA, orientation, upper & lower extremity movement & strength
- Re-orient client, provide cues or demonstrations for sequence of steps for ADLs
- Seek assistance from Occupational therapy
12
Q
**Neurologic **
Impaired communication related to aphasia (difficulty with speaking or understanding communication)
or
related to dysarthria (difficulty pronouncing words, slurred speech)
A
- Speak slowly and calmly, using simple words or sentences.
- Ask questions that can be answered with “yes” or “no”
- Present one thought at a time.
- Give extra time to comprehend and respond to communication.
- Use of visuals i.e. gestures, demonstrations
13
Q
Visual Disturbances
- Visual disturbances related to visual field cut (homonymous hemianopia)
- Visual disturbances related to agnosia (difficulty recognizing familiar objects through the senses)
A
- Place yourself on their unaffected side
- Arrange food tray so that all food is on the unaffected side, place personal items on unaffected side. A mirror is another idea
- Encourage patient to use cues to help recognize objects or people.
- Consistency in task stimuli
- Perception of a client with homonymous hemianopia shows that food on the left side is not seen and thus ignored.
14
Q
Sensation
Potential for injury related to sensory loss (i.e. not able to distinguish hot from cold)
A
- Reduce environmental hazards i.e. reduce risk for burns, skin breakdown.
- Ensure environment is uncluttered
15
Q
Psychosocial
A
Self-Concept
Body image disturbance
- Sexual dysfunction
- Unresolved loss
- Anxiety
- Powerlessness
- Low self esteem
- Hopelessness
- Morale distress
- Sorrow
Role Function
- Role conflict
- Ineffective role transition
Interdependence
- Ineffective pattern of dependency & independency
- Inadequate resources
