CEREBROVASCULAR ACCIDENT A sudden neurologic incident related to impaired cerebral blood supply, WHICH MAYBE CAUSED BY HEMORRHAGE, EMBOLISM

OR THROMBOSIS RESULTING IN ISCHEMIA OF THE brain. The clinical manifestations of stroke vary depending on the area of brain affected.

Nursing Diagnoses: High Risk for Injury: Alteration in Integrated Regulation Nursing Intervention: y y y Position upright to facilitate work of breathing: monitor blood pressure closely during any position changes. Prevent pooling secretions: change position q2-4hours, encourage deep breathing, add humidity in the environment. Provide respiratory support: * Administer supplemental oxygen as prescribed. *Provide endotracheal or tracheal care: Maintenance of the patent airway is first priority. * Avoid respiratory measures that increase intracranial secretions. * Instruct deep breathing techniques. Restrict physical activity initially; patient gradually resumes activity as tolerated. To reduce myocardial oxygen consumption. Control body temperature: administer antipyretics. Review medications for side effects on fluid and electrolyte imbalance. Explain medication to the patient. Maintain volume status by replacing or restrict fluids as prescribed Administer vasopressin as prescribed.

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Nursing Diagnoses: Impaired physical mobility related to generalized body weakness as evidenced by limited ROM Nursing Intervention: y y y Change position of the patient at least every 2 hours. Keep track of the position changes with a turning schedule. Perform active and passive range of motion exercise in all extremeties several times daily to improve muscle strength and prevent contractures. Increase functional activities as strength improves and the patient is medically stable.

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Teach family and patient exercises and transfer techniques. Monitor skin integrity for areas of blanching and redness as sign of potential breakdown.

For balance and coordination problems: y y y y Assist patient in performing movement or task; begin with small range of movements and encourage control. Encourage focusing on proximal control initially and distal muscle control. This especially helps patients with ataxia. Teach patient and family excercises and techniques to improve balance and coordination. Reinforce safety precautions with family and patient.

For increased muscle tone (spasticity) y y y y Perform activities in quiet environment. Apply heat and cold to extremities in an effort to reduce tone before initiating movement. Give medications for spasticity. Instruct family in concepts of spasticity and ways to reduce tone.

Nursing Diagnoses: High risk for impaired verbal Communication Nursing Intervention: y y y y y y y y y y Modulate personal communication, controlling body language and providing clear and simple directions. Incorporate multimodality input to enhance function in intact speech and language areas. Use written materials to supplement auditory input. Use prompting clues. Allow adequate time for patient s response. Provide opportunities for spontaneous conversation. Anticipate patient needs until alternative means of communication can be established. Provide reality orientation and focus attention Encourage family to attempt communication with patient. Demonstrate to patient progress made.

Nursing Diagnoses: High risk for sensory/ perceptual Alterations Nursing Intervention: y y y y y y Perform regular skin inspections and instruct patient in techniques to do the same. Explain consequences of excess pressure on the skin. Provide tactile stimulation to affected limbs using rough cloth or hand and instruct family/patient in method used. Explain how stimulus might feel. Teach patient to check temperature of water with unaffected side before using water. Regularly move affected limbs. Enhance environment for optimum safety.

Nursing Diagnoses: Sensory/ Perceptual Alterations/ Unilateral Neglect Nursing Intervention: y Approach patient from unaffected side during the acute phase; approach patient from the affected side during the rehabilitation phase. Tjis will encourage the patient to use affected side of body and environment. Ensure safe environment with call bell on patient s unaffected side. Provide tactile stimulation to affected side and approach patient in the affected side,calling patient s name to encourage overcoming neglect. Place all food in small quantities, arranged simply on plate. Attach watch or bright bracelet to affected arm to draw patient s attention. Provide a mirror for visual cues with ADL s; assist the verbal cues. Practice with patient manipulating objects. Practice drawing and copying figures with patient. Draw bright mark on sides of paper when patient is reading to give cue to read entire line and return to next line. Teach compensatory strategies such as visual scanning to reduce chance of injury.

y y y y y y y y y

MULTIPLE SCLEROSIS A chronic progressive nervous system disease characterized by scattered patches of demyelination and glial tissue overgrowth in the white matter of the brain and spinal cord leading to decrease nerve conduction. As the inflammation/ edema diminish, some remyelination may occur, and nerve

conduction returns. Among the clinical symptomsassociated with physical sclerosis are extremity weakness, visual disturbances, ataxia, tremor, uncoordination, sphincter impairment, and impaired position sense. Remissions and exacerbations are associated the disease. Nursing Diagnoses: Impaired physical mobility Nursing Intervention: y y y y y y y Orientt patient to environment as appropriate. Place objects within the reach. Provide eyepatch for diplopia; encourage alternating patch from eye to eye. Instruct patient to rest eyes when fatigued. Advise of availability of large-type reading materials and talking books. Place call light within reach with side rails up and bed in low position to prevent injury. Place sign over bed; indicate visual impairment chart.

Nursing Diagnoses: High Risk for Altered Pattern of Elimination: Urinary frequency/Retention Nursing Intervention: y y y y Measure urine output; catheterize for residual urine as indicated. Initiate individual bladder training program; instruct the patient about the Crede method, intermittent catheterization, signs and symptoms of urinary tract infection, time of voiding. Administer medications as prescribed. Cholinergic drugs are indicatued for flaccid bladder and anticholinergic for spastic bladder. Recommend vitamin C and liberal intake of cranberry juice to acidify urine and reduce bacterial growth.

Nursing Diagnoses: High Risk for Impaired Skin Integrity Nursing Intervention: y y Avoid heat, cold and pressure. Instruct the patient to test bath water with unaffected extremety.

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Instruct the patient to notice foot placement when ambulating to compensate for decreased position sense. Instruct to change position every 2 hours.

Nursing Diagnoses: Body Image Disturbances Nursing Intervention: y y y y y Make frequent, unhurried patient contact. Provide opportunity to ask questions and talk about feelings. Verbalization provides outlet for concerns. Include patient in care planning. May foster positive self-concept/ body image. Support patient s efforts to maintain independence. Refer to a support group.

Nursing Diagnoses: Knowledge Deficit Nursing Intervention: y y y y Discuss disease process in simple straight forward manner. Instruct patient/ significant others when to contact health team. Instruct patient/ significant others about the steroid theraphy, side effects and measure to control side effects. Instruct of: o Imporance of maintaining most normal activity level possible to maintain functional limits and body image. o Avoidance of hot baths(increase metabolic demands and may increase weakness). o Sleeping in a prone position to decrease flexion spasm. o Need to inspect areas of impaired sensations for sereous injuries. o Need to use energy conservation techniques. Instruct to avoid potencially exacerbating activities: emotional stress, physical stress/ fatigue, infection, pregnancy, physically run down condition.

PARKINGSONISM

It s a movement disorder associated with dopamine deficiency in the brain. Other neurotransmitter alterations may also contribute to the disease process. Tjis chronic neurological disorder affects the extrapyramidal system of the brain responsible for control and regulation of movement. The clinical manifestations are tremor at rest, rigidity, slowness of movement, shuffling gait, masklike facial expressions and muscle weakness affecting writing, speaking, eating, chewing and swallowing. Nursing Diagnoses: Impaired physical Mobility Nursing Intervention: y y y y y y y Allow sufficient time for ADL. Nursing staff/family frequently want to perform task rather than enable patient to do it. Encourage ROM to all joints twice daily. Supervise and assist with ambulation. Activity is important to reduce hazards of immobility. Encourage patient to lift feet and take large step while walking to improve balance and minimize shuffling. Consult physical and occupational therapists about the aids to facilitate ADL and safe ambulation and promote muscle strengthening. Remove environmental barriers. Provide tips for getting in and out of chair.

Nursing Diagnoses: Impaired verbal Communication Nursing Intervention: y y y y y y y y Place call light and other articles within the reach. Maintain eye contact when speaking. Allow patient time to articulate. Encourage face and tongue exercises to reduce rigidity. Avoid speaking loudly unless patient is deaf. Consult speech therapist if indicated. Encourage patient to practice reading aloud. Provide alternative communication aid as needed.

Nursing Diagnoses: Altered Nutrition: Less than body requirements Nursing Intervention: y y y y y y y y Place patient inhigh Fowler s position for eating and drinking. Supervise patient during meals. Avoid distractions to help patient focus on swallowing. Allow time for meals; avoid rushing patient to frustrations. Offer high calorie, low volume supplements between meals to provide additional caloric intake. Offer small bites of food, which maybe easier to swallow. Encourage patient to swallow 2-3 times after taking a bite of food. Provide thickened rather than watery foods. Consult Dietitian for needed changes in food consistency and for caloric counts. Assist with oral hygiene after meals. Consult the speech therapist to evaluate swallowing.

Nursing Diagnoses: High Risk for Urinary Incontinence Nursing Intervention y y y y y y y y Evaluate previous pattern of voiding. Evaluate intervals between voiding. Assess amount frequency, character, color, odor, specific gravity. Evaluate current medications that may contribute to urinary problems. Evaluate I & O. Place bedpan/ urinal/ bedside commode within the reach. Assist patient in identifying regular intervals to go to bathroom, and assist to do do. Decrease fluid intake after 6pm to reduce need for frequent nighttime urination. Institute intermittent catheterization of foley catheter as indicated.

Nursing Diagnoses: Self-esteem Disturbance Nursing Intervention: y y y Encourage patient to verbalize fears and concerns. Listen attentively to facilitate development of trust. Discuss feelings about symptoms: tremors, drooling of saliva, slurred speech. Discuss normasl impact of alterations in health status on self-esteem. Use the lay of support groups may help patient yto recognize positive even in face of disease.

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Explore strength and resources with patient. Advise of realistic need for additional support and coping with lifelong illness. Avoid overprotection of individual; promote social interaction as appropriate. Clarify patient s misconceptions and provide accurate information. Provide privacy as needed especially when performing ADL. Teach patient necessary self care meadures relasted to disease. Each success will reinforce positive self esteem. Teach patient the harmful effects of negative talk about self.

Nursing Diagnoses: Knowledge Deficit Nursing Intervention: y y y y y Reinforce explanation of disease and treatment. Encourage independence and avoid overprotection by permitting patient to do things for self: self care, feeding, dressing, ambulation. Discuss with patient and family about the medications that it should be given 20-30 minutes before meals. For patients taking levodopa, high protein foods such as milk, meat, fish, cheese, eggs, peanuts, grains and soybeans should be limited. They delay absorption of medication Diet: o High-caloric , soft diet is recommended. o Finger food is easier for patient to manage independently. o Utensils should be within the reach. o Use blender for tick foods. o Maintain 2000-ml/day liquid intake. o Offer frequent small feedings. o Use straws and bibs for excess drooling. o Instruct patient to swallow slowly and take small bites of food. Activity: o Plan rest periods. o Encourage passive and active ROM exercises to all extremeties. o Encourage family/ significant others to participate in physical theraphy excercises of stretching ang massaging muscles. o Encourage daily ambulation outdoors but avoidance of extreme hot and cold weather. o Encourage patient to practice lifting feet while walking, using heel-toe gait and swinging deliberately while walking. o Avoid sitting for long periods. Stiffness may occur. o Offer divertional activities depending on extent of tremors and disability.

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Prevent falls by cleaning the walkways of furniture and throw rugs and provide siderails on stairs. Speech therapy: o Instruct patient to slowly and practice reading aloud in exaggerated manner. Oral hygiene: Perform q2-4 and prn(especially if drooling) and have tissues accessible to patient. Elimination: o Institute voiding measures as needed. o Institute bladder control program as needed. o Raise toilet seats with siderails at home to facilitate sitting or standing. o Avoid constipation, encourage fluids, use of natural laxatives and stool softeners as needed. o