Nursing Management of Acute Stroke

Collaborative Care
1. Acute Care
  1. Airway maintenance (Macauley, 2014).
  2. Fluid Therapy (Macauley, 2014).
  3. Treatment of cerebral edema (Macauley, 2014)
  4. Prevent secondary injury (Macauley, 2014).
2. Surgical Therapy
3. Drug Therapy
4. Prevention
  1. Lifestyle Modifications
Disease Process
1. Pathophysiology
  1. Ischemic Stroke
    1. Thrombotic
      1. A blood clot formed in the brain, this is usually attributed to atherosclerosis (Marsh & Banasik, 2013).
    2. Embolic
      1. Blockage of brain artery by a blood clot from the heart (Marsh & Banasik, 2013)
    3. Occurs following the occlusion of a cerebral artery by a thrombus or embolus (Marsh & Banasik, 2013).
      1. Causes ischemia, which can lead to necrosis and irreversible tissue damage (Marsh & Banasik, 2013)
  2. Hemorrhagic Stroke
    1. Bleed in brain parenchyma resulting from severe hypertension (Marsh & Banasik, 2013)
2. Symptoms
  1. Motor and Sensory Defecits
    1. Footdrop, outward rotation of leg, dependent edema (Marsh & Banasik, 2013).
    2. Motor paralysis opposite to affected side of brain (Marsh & Banasik, 2013)
    3. Decreased muscle tone in affected limbs called flaccidity (Marsh & Banasik, 2013)
    4. Muscle Atrophy
    5. dysphagia
  2. Cognitive Deficits
    1. Language deficit
    2. Limited spacial awareness
    3. Reduced-short term memory
    4. Learning Impairments
    5. Impaired judgement
    7. visual disturbance
  3. Language Defecits
    1. Aphasia, decreased vocabulary, diminished, attention span, inability to use learned linguistic rules (Marsh & Banasik, 2013).
  4. Nausea, vomiting
  5. headache
  6. Change in bowel and bladder function
Client and Family Centered Care
1. Emotional support for caregiver necessary to address feelings of anxiety and being overwhelmed (Platten, 2014).
2. Integrating families preferences and beliefs into decision making can enhance stroke outcomes (Krishnan et al., 2017).
3. Enable and encourage individuals to create goals that they will respond to and work together to achieve them (Kidd et al., 2015).
4. Targeted assessments to discover clinical severity and functional status, including individuals priorities to determine support needs and barriers to outcomes (Kidd et al., 2015)
5. Recognize clients perspectives and expectations about care and base nursing care around these (Kidd, et al., 2015).
6. Emotional Support Post stroke to combat loss of confidence, anxiety and depression (Platten, 2014).
7. Stimulate client initiated goals through motivational interviewing lead by the patient to determine their motivation for change (Kidd et al., 2015)
Nursing Care
1. Assessment
  1. Subjective
    1. Health History
    2. Symptoms
  2. Objective
2. Diagnosis
3. Planning
4. Implementation

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Nursing Management of Acute Stroke

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	Criado por Meagan Javornich aproximadamente 7 anos atrás