About
Otherwise know as a "stroke" or "brain attack", ischemia occurs in the brain as a result of a hemorrhage, embolism ( blood clot), or thrombosis cutting off blood supply to areas of the brain.
Assess
Genetic history; hx. Of hypertension, aneurysms, CAD, heart disease; neurological assessment, cognitive, motor, sensory changes
Complications
Paralysis; impaired cognition; impaired swallowing; impaired communication
Increased intracranial pressure; disease specific complications
Diagnosis
- Self care deficit related to altered thought processes
- Impaired tissue perfusion: cerebral related to vascular changes
- Impaired mobility related to neurological changes effecting movement
- Risk for aspiration related to impaired gag reflex
- Incontinence: urinary and bowel related to changes in ability to control elimination
- Impaired verbal communication related to neurological impact on communication centers
Goals
- The client will be free from injuries.
- The client will utilize adaptive techniques, as indicated, to improve mobility, speech, and participation in ADL's.
Interventions
- Emergent treatment: immediately assess airway and neurological status, onset of symptoms, duration. May give rtPA if within three hours of ischemic stroke, as ordered.
- Monitor neurological status, vital signs, pulse oximetry, circulation.
- Monitor for s/s of increased intracranial pressure ( seizures, non-responsiveness, nausea, vomiting, hypertension, bradycardia, changes in neuro status).
- Reposition client every two hours.
- Initiate injury prevention strategies ( call light within reach, aspiration precautions, etc.).
- Assist with meals, noting difficulty with swallowing.
- Encourage communication via alternative methods if patient unable to speak.
- Encourage active participation with ADL's.
- Initiate bowel and bladder retraining or monitor for incontinence frequently.
- Encourage active participation in rehabilitative activities to restore or adapt to decreased levels of functioning.
- Administer medications ( anticoagulants, antihypertensives, etc.) as ordered.
- Teach all aspects of treatment and maintenance to client and family member.
- Monitor for signs/ symptoms of complications.
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