PRESENTORS

Daluma, Moh. Ashraf

Dato, Rowena

Dequeros, Hannah Angeleah

De Pablo Ma. Catherine Ruby

Gargoles, Liezle

Gumayao, Jeanette

Guro, Hanieyah

Honghong, Ma. Sofia Mae

Jacinto, Jane

Lacsi, Paul Garret

BSN - 4C

TABLE OF CONTENTS

PAGE

Objectives....................................................................................................................................................................................................................................... 1

Glossary.......................................................................................................................................................................................................................................... 2

Introduction ................................................................................................................................................................................................................................... 3

Review of Normal Anatomy and Physiology............................................................................................................................................................................... 5

Simplified Pathophysiology........................................................................................................................................................................................................... 8

Physical Examination and Review of Systems............................................................................................................................................................................ 10

Diagnostic Tests.............................................................................................................................................................................................................................. 13

Pharmacology................................................................................................................................................................................................................................. 20

Nursing Care Plan

s........................................................................................................................................................................................................................ 30

Surgical Managements...................................................................................................................................................................................................................

43

Health Education Plan...................................................................................................................................................................................................................

45

Discharge Plan................................................................................................................................................................................................................................ 46

Prognosis......................................................................................................................................................................................................................................... 48

Bibliography.................................................................................................................................................................................................................................... 49

Presentor-Centered

After 1 and ½ hour of case presentation, the presentors will be able to:

1. Explain what cerebrovascular accident is and be able to enumerate and discuss its various types.

2. Compare the types of cardiovascular accident including their causes, clinical manifestations, and medical management.

3. Describe the incidence and social impact of cerebrovascular disorders.

4. Conduct a review on the anatomy and physiology of the systems and organs involved.

5. Identify the risk factors for cerebrovascular accident and related measures for prevention.

6. Discuss the principles of nursing management to the care of a patient recovering from an ischemic stroke or of a patient with a hemorrhagic stroke.

7. Identify essential elements for family teaching and preparation for home care of the patient who has had a stroke.

Critique Group - Centered

After 1 and ½ hour of case presentation, the audience, particularly the students will be able to:

1. State a summary description of cerebrovascular accident and be able to identify its major types.

2. Explain the difference between the types of cerebrovascular accident by comparing its causes, clinical manifestations and medical management

3. Give details on the epidemiology of cerebrovascular accident both locally and internationally.

4. Determine the different assessment parameters in assessing client with cerebrovascular accident

5. Describe and discuss the purpose of each diagnostic test that will be tackled.

6. Identify the contributing factors including the predisposing and precipitating factors associated in the variety of illnesses.

7. Discuss managements on how to handle patient’s with same diagnosis.

8. Raise sensible and relevant questions or clarifications on the case that is going to be presented.

CI-Centered

After 1 and ½ hour of class presentation, the clinical instructors will be able to:

1. Share additional information about the case that is going to be presented.

2. Ask clarifications or questions if some information presented were unclear or erroneous.

3. Provide suggestions on how to improve the study.

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OBJECTIVES

Agnosia: Impairment of the ability to recognize or comprehend the meaning

of various sensory stimuli.

Aneurysm: A weakening or bulge in an arterial wall.

Aphasia: Inability to express oneself or to understand language

Apraxia: Disorder of voluntary movement consisting of impairment of the

performance of skilled or purposeful movements despite physical ability

and willingness to move.

Atheroma: A fibrous cap composed of smooth muscle cells that forms over

lipid deposits within arterial vessels and that protrudes into the lumen of

the vessel, narrowing the lumen and obstructing blood flow; also called

plaque.

Atherosclerosis: Abnormal accumulation of lipid deposits and fibrous tissue

within arterial walls and lumen.

Atrial fibrillation: Most common form of irregular heartbeat and a risk factor

for embolic ischemic stroke. The condition can cause a pooling of blood in

the heart, which can make it easier for clots to form.

Carotid stenosis: Buildup of hardened plaque on the carotid artery wall. This

is the leading cause of ischemic stroke.

Cerebral edema: Swelling of the brain.

Contralateral: Refers to the other side. Stroke affecting the right side of the

brain may cause paralysis, affecting the left arm and leg.

Dysarthria: Difficulty in articulating words due to disease of the central

nervous system (CNS).

Dysphagia: Difficulty in swallowing.

Embolic stroke: Occurs when a clot is carried into cerebral circulation and

causes a localized cerebral infarct.

Embolus: Blood clot that forms in one area of the body and moves to

another.

Expressive aphasia: Inability to express oneself; often associated with

damage to the left frontal lobe area.

Hemianopsia: Blindness of half of the field of vision in one or both eyes.

Hemiparesis: Weakness one side of the body, or part of it, due to an injury in

the motor area of the brain.

Hemiplegia: Paralysis of one side of the body, or part of it, due to an injury in

the motor area of the brain.

Infarction: A zone of tissue deprived of blood supply.

Ipsilateral: Refers to the same side. A stroke on the right side of the brain

causes some symptoms on the right side of the body, as opposed to

contralateral (the other side).

Ischemia: Insufficient tissue oxygenation.

Korsakoff’s syndrome: Disorder characterized by psychosis, disorientation,

delirium, insomnia, and hallucinations.

Penumbra region: Area of low cerebral blood flow receptive aphasia:

inability to understand what someone else is saying; often associated with

damage to the temporal lobe area.

Thrombosis: Obstruction of a blood vessel by a clot formed at the site of

obstruction.

Thrombotic stroke: Type of ischemic stroke usually seen in aging

population. It is due to atherosclerosis (plaque buildup), eventually

narrowing the lumen of the artery. The symptoms are much more gradual

and less dramatic than other strokes due to the slow, ongoing process that

produces it. The stroke is “completed” when the condition stabilizes.

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GLOSSARY

Transient ischemic attack (TIA): Temporary lack of adequate blood and

oxygen to the brain that causes stroke warning signs but no permanent

damage. Generally lasts about 1 minute, but can last up to 5 minutes.

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CEREBROVASCULAR ACCIDENT

Cerebrovascular accident (CVA, “stroke” or “brain attack”) is injury or death to parts of the brain caused by an interruption in the blood supply to that area causing disability, such as paralysis or speech impairment. It can be divided into two major categories: ischemic (85%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (15%), in which there is extravasation of blood into the brain or subarachnoid space. Although there are some similarities between the two broad types of stroke, differences exist in etiology, pathophysiology, medical management, surgical management, and nursing care. The term brain attack has been promoted to highlight that time-dependent tissue damage occurs and to raise awareness of the need for rapid emergency treatment, similar to that with heart attack.

TYPES

Ischemic stroke

An ischemic stroke, cerebrovascular accident (CVA), or “brain attack” is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. The term brain attack is being used to suggest to health care practitioners and the public that a stroke is an urgent health care issue similar to a heart attack. Urgency is needed on the part of the public and health care practitioners for rapid transport of the patient to a hospital for assessment and administration of the medication.

Ischemic strokes are subdivided into five different types based on the cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%).

Large artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction (deprivation of blood supply).

Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke. Small artery

thrombotic strokes are also called lacunar strokes because of the cavity that is created after the death of infarcted brain tissue.

Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. Embolic strokes can also be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulation therapy in patients with atrial fibrillation.

The last two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.

Ischemia may be transient and resolve within 24 hours, be reversible with resolution of symptoms over a period of 1 week (reversible ischemic neurological deficit [RIND]), or progress to cerebral infarction with variable effects and degrees of recovery.

Hemorrhagic strokeHemorrhagic strokes are caused by bleeding into the brain tissue, the

ventricles, or the subarachnoid space. Hemorrhagic strokes are primarily caused by intracranial or subarachnoid hemorrhage. The most common predisposing factors are advancing age and hypertension. Other causes of hemorrhage are aneurysm, trauma, erosion of the vessels by tumors, arteriovenous malformations, blood coagulation disorders, vasculitis, and drugs.

EPIDEMIOLOGY

According to the World Health Organization, 1 in ten in the 55 million deaths that occurs every year worldwide is due to stroke and two-thirds of which occur in people living among developing countries. Strokes are much more common among older people than among younger adults, usually because the disorders that lead to strokes progress over time. Over two thirds of all strokes occur in people older than 65. Slightly more than 50% of all

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WHAT IS CVA?

strokes occur in men, but more than 60% of deaths due to stroke occur in women, possibly because women are on average older when the stroke occurs. According to the latest WHO data published in April 2011 Stroke Deaths in Philippines reached 40,245 or 9.55% of total deaths. The age adjusted Death Rate is 82.77 per 100,000 of population ranks Philippines #106 in the world.

RISK FACTORS

Among the major risk factors for stroke are age (65-74 years old), sex (male: 19% greater risk), race (African Americans: 60% greater risk), family history, hypertension, smoking, diabetes mellitus, asymptomatic carotid stenosis, sickle cell disease, hyperlipidemia, and atrial fibrillation. Other less well-documented risk factors include obesity, physical inactivity, alcohol and drug abuse, hypercoagulability disorders, hormone replacement therapy, and oral contraceptive use.

CLINICAL MANIFESTATIONS

Ischemic Stroke

An ischemic stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which vessels are obstructed), the size of the area of inadequate perfusion, and the amount of collateral (secondary or accessory) blood flow. The patient may present with any of the following signs or symptoms:

Numbness or weakness of the face, arm, or leg, especially on one side of the body

Confusion or change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty walking, dizziness, or loss of balance or coordination Sudden severe headache

Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted.

Hemorrhagic Stroke

The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious

patient most commonly reports a severe headache. A comprehensive assessment reveals the extent of the neurologic deficits. Many of the same motor, sensory, cranial nerve, cognitive, and other functions that are disrupted after ischemic stroke are also altered after a hemorrhagic stroke.

Other symptoms that may be observed more frequently in patients with acute intracerebral hemorrhage (compared with ischemic stroke) are vomiting, an early sudden change in level of consciousness, and possibly focal seizures due to frequent brain stem involvement.

In addition to the neurologic deficits (similar to those of ischemic stroke), the patient with an intracranial aneurysm or AVM may have some unique clinical manifestations.

Rupture of an aneurysm or AVM usually produces a sudden, unusually severe headache and often loss of consciousness for a variable period of time. There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to meningeal irritation. Visual disturbances (visual loss, diplopia, ptosis) occur if the aneurysm is adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemiparesis may also occur.

COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES

Left Hemispheric Stroke Right Hemispheric Stroke

Paralysis or weakness on right side of the bodyRight visual field deficitAphasia (expressive, receptive or global)Altered intellectual abilitySlow cautious behavior

Paralysis or weakness on left side of the bodyLeft visual field deficitSpatial-perceptual deficitsIncreased distractibilityImpulsive behavior and poor judgmentLack of awareness of deficits

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THE CENTRAL NERVOUS SYSTEM

THE BRAIN

The brain accounts for approximately 2% of the total body weight; in an average young adult, the brain weighs approximately 1400g, whereas in an average elderly person, the brain weighs approximately 1200g. The brain is divided into three major areas: the cerebrum, the brain stem, and the cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the hypothalamus, and the basal ganglia. The brain stem includes the midbrain, pons, and medulla. The cerebellum is located under the cerebrum and behind the brain stem (Fig. 1).

Cerebrum

The outside surface of the hemispheres has a wrinkled appearance that is the result of many folded layers or convolutions called gyri, which increase the surface area of the brain, accounting for the high level of activity carried out by such a small-appearing organ. Between each gyrus is a sulcus or fissure that serves as an anatomic division. In between the cerebral hemispheres is the great longitudinal fissure that separates the cerebrum into the right and left hemispheres. The two hemispheres are joined at the lower portion of the fissure by the corpus callosum. The external or outer portion of the hemispheres (the cerebral cortex) is made up of gray matter approximately 2 to 5 mm in depth; it contains billions of neuron cell bodies, giving it a gray appearance. White matter makes up the innermost layer and is composed of myelinated nerve fibers and neuroglia cells that form tracts or pathways connecting various parts of the brain with one another. These pathways also

connect the cortex with lower portions of the brain and spinal cord. The cerebral hemispheres are divided into pairs of lobes as:

Frontal - the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca’s area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person’s affect, judgment, personality, and inhibitions.

Parietal - a predominantly sensory lobe posterior to the frontal lobe. This lobe analyzes sensory information and relays the interpretation of this information to other cortical areas and is essential to a person’s awareness of body position in space, size and shape discrimination, and right–left orientation.

Temporal - located inferior to the frontal and parietal lobes, this lobe contains the auditory receptive areas and plays a role in memory of sound and understanding of language and music.

Occipital - located posterior to the parietal lobe, this lobe is responsible for visual interpretation and memory. The corpus callosum (Fig. 2), a thick collection of nerve fibers that connects the two hemispheres of the brain, is responsible for the transmission of information from one side of the brain to the other. Information transferred includes sensation, memory, and learned discrimination. Right-handed people and some left-handed people have cerebral dominance on the left side of the brain for verbal, linguistic, arithmetic, calculation, and analytic functions.

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REVIEW OF NORMAL ANATOMY AND PHYSIOLOGY

The nondominant hemisphere is responsible for geometric, spatial, visual, pattern, and musical functions. Nuclei for cranial nerves I and II are also located in the cerebrum. The basal ganglia are masses of nuclei located deep in the cerebral hemispheres that are responsible for control of fine motor movements, including those of the hands and lower extremities.

The thalamus (see Fig. 2) lies on either side of the third ventricle and acts primarily as a relay station for all sensation except smell. All memory, sensation, and pain impulses pass through this section of the brain. The hypothalamus (see Fig. 2) is located anterior and inferior to the thalamus, and beneath and lateral to the third ventricle. The infundibulum of the hypothalamus connects it to the posterior pituitary gland. The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. In addition, the hypothalamus is the site of the hunger center and is involved in appetite control. It contains centers that regulate the sleep–wake cycle, blood pressure, aggressive and sexual behavior, and emotional responses (ie, blushing, rage, depression, panic, and fear). The hypothalamus also controls and regulates the autonomic nervous system. The optic chiasm (the point at which the two optic tracts cross) and the mamillary bodies (involved in olfactory reflexes and emotional response to odors) are also found in this area.

Brain Stem

The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 1). The midbrain connects the pons and the cerebellum with the cerebral hemispheres; it contains sensory and motor pathways and serves as the center for auditory and visual reflexes. Cranial nerves III and IV originate in the midbrain. The pons is situated in front of the cerebellum between the midbrain

and the medulla and is a bridge between the two halves of the cerebellum, and between the medulla and the midbrain. Cranial nerves V through VIII originate in the pons. The pons also contains motor and sensory pathways. Portions of the pons help regulate respiration. Motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain are located in the medulla. Most of these fibers cross, or decussate, at this level. Cranial nerves IX through XII originate in the medulla. Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing are located in the medulla as well. The reticular formation, responsible for arousal and the sleep–wake cycle, begins in the medulla and connects with numerous higher structures.

Cerebellum

The cerebellum is posterior to the midbrain and pons, below the occipital lobe (see Fig. 1). The cerebellum integrates sensory information to provide smooth coordinated movement. It controls fine movement, balance, and position (postural) sense or proprioception (awareness of where each part of the body is).

Cerebral Circulation

The brain does not store nutrients and requires a constant supply of oxygen. These needs are met through cerebral circulation; the brain receives approximately 15% of the cardiac output, or 750mL per minute of blood flow. Brain circulation is unique in several aspects. First, arterial and venous circulation are not parallel as in other organs in the body; this is due in part to the role the venous system plays in CSF absorption. Second, the brain has collateral circulation through the circle of Willis, allowing blood flow to be redirected on demand. Third, blood vessels in the brain have two rather than three layers, which may make them more prone to rupture when weakened or under pressure.

Arteries

Arterial blood supply to the brain originates from the common carotid artery, the first bifurcation off the aorta. The internal carotid arteries arise at the bifurcation of the common carotid and supply much of the anterior circulation of the brain. Branches of the internal carotid arteries, anterior and middle cerebral arteries, along with their connections, anterior and posterior communicating arteries, form the circle of Willis (Fig. 3).

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The vertebral arteries branch from the subclavian arteries to supply most of the posterior circulation of the brain. At the level of the brain stem, the vertebral arteries join to form the basilar artery. The basilar artery divides to form the two branches of the posterior cerebral arteries. Functionally, the posterior portion of the circulation and the anterior or carotid circulation usually remain separate. However, the circle of Willis can provide collateral circulation if one of the vessels supplying it becomes occluded or is ligated. The bifurcations along the circle of Willis are frequent sites of aneurysm formation. Aneurysms are outpouchings of the blood vessel due to vessel wall weakness. Aneurysms can rupture and cause a hemorrhagic stroke.

Veins

Venous drainage for the brain does not follow the arterial circulation as in other body structures. The veins reach the brain’s surface, join larger veins, then cross the subarachnoid space and empty into the dural sinuses, which are the vascular channels laying within the dura (see Fig. 4). The network of the sinuses carries venous outflow from the brain and empties into the internal jugular veins, returning the blood to the heart. Cerebral veins are unique because, unlike other veins in the body, they do not have valves to prevent blood from flowing backward and depend on both gravity and blood pressure for flow.

Blood–Brain Barrier

The CNS is inaccessible to many substances that circulate in the blood plasma (eg, dyes, medications, and antibiotics) because of the blood–brain barrier. This barrier is formed by the endothelial cells of the brain’s capillaries, which form continuous tight junctions, creating a barrier to macromolecules and many compounds. All substances entering the CSF must filter through the capillary endothelial cells and astrocytes. The blood–brain barrier has a protective function but can be altered by trauma, cerebral edema, and

cerebral hypoxemia; this has implications in the treatment and selection of medication for CNS disorders.

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PREDISPOSING FACTORS

Advance age (65-74 years old) Sex (male: 19% greater risk) Race (African Americans: 60% greater risk) Family history

Atheroma/Thrombus formation in the cerebral artery

Travel to the blood stream

Embolus formation from outside of the brain(Plaque, Clots, Tumor, Bacteria, Air)

Arterial wall thinning and loss of elasticity

Structural change of arterial wall

Arterial stenosis

PRECIPITATING FACTORS

Hypertension Smoking Hyperlipidemia Atrial fibrillation. Obesity Physical inactivity Alcohol and drug abuse Hormone replacement therapy Oral contraceptive use Diabetes mellitus Asymptomatic carotid stenosis Sickle cell disease

causes

promote

progresses towhich may

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Narrowing of an arterial lumen

Intracranial Hemorrhage

Lodges in a cerebral arteryRupture of an artery

ISCHEMIC STROKE

Cerebral Ischemia

Decrease cerebral tissue PerfusionHEMORRHAGIC

STROKE

Energy Failure

Partial/Total occlusion of a cerebral artery

Increase ICPHypovolemic Shock

Increase Glutamate formation

Ion imbalanceAcidosis

Increase intracellular calcium

Depolarization

may result to

results to

Breakdown of cell membranes and proteins

leads to

Cell injury and death

results toresults to

causes

leads to

results to

which results to

results to

promotes

leads to

leads to

leads to

and then leads to

results to

causes

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Neurologic Deficits

Brain infarction

results to

results to

AREAS SUBJECTIVE FINDINGS (Patient may report)

OBJECTIVE FINDINGS (Patient may exhibit)

PROBLEM IDENTIFIED

General Health Survey

• Feelings of helplessness, hopelessness • Emotional lability• Depression• Withdrawal• Exaggerated or inappropriate responses to

anger, sadness, happiness• Inappropriate use of defense mechanisms• Difficulty expressing self• Guarding, distraction behaviors• Restlessness• Staggering, unsteady gait• Unable to keep feet together; needs a broad

base to stand

• Ineffective cerebral tissuepPerfusion• Impaired verbal [and/or written]

Communication• Disturbed Sensory Perception• Disturbed thought process• Risk for Ineffective Coping• risk for Injury• Risk for fall• situational low Self-Esteem• Anxiety

Integumentary System

• Tingling and numbness • Inability to respond to pressure and discomfort

• Hypoxia• Hypercapnia• >2 sec CRT

• Disturbed sensory perception• Risk for Impaired Skin Integrity• Risk for decreased tissue perfusion

HEENT • Headache of varying intensity• Numbness or weakness of the face.• Loss of sensation in tongue, cheek, and

throat• Dysphagia• Disturbance in senses of taste, smell

• Muscle or facial tension• Facial droop, presence of ptosis• Pupil size and reaction: May be unequal;

dilated and fixed pupil on the ipsilateral side may be present with

• Difficulty seeing at night• Double vision• Difficulty seeing objects on left side (right

CVA)• Chewing and swallowing problems• Loss of gag or cough reflexes

• Acute Pain• Impaired physical Mobility• Impaired Swallowing• Disturbed thought process• Unilateral Neglect• Risk for Injury• Risk for fall• Risk for aspiration• Risk for imbalanced Nutrition: Less than

Body Requirements• Situational low Self-Esteem• Risk for disturbed Body Image

Neck • Nuchal Rigidity • Impaired physical Mobility

Respiratory System

• History of smoking • Labored and irregular respirations• Hypoventilation• Hypoxemia• Loss of cough reflexes• Noisy respirations, rhonchi (aspiration of

secretions)

• Impaired breathing pattern• Risk for decreased tissue perfusion• Risk for ineffective airway clearance• Risk for impaired spontaneous

ventilation• Risk for aspiration

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PHYSICAL EXAMINATION AND REVIEW OF SYSTEM

Cardiovascular System

• History of cardiac disease—myocardial infarction (MI),rheumatic and valvular heart disease, heart failure (HF),bacterial endocarditis, polycythemia

• Arterial hypertension, which is common unless CVA is due to embolism or vascular malformation

• Pulse rate may vary due to various factors, such as preexisting heart conditions, medications, effect of stroke on vasomotor center

• Dysrhythmias, electrocardiographic (ECG) changes

• Bruit in carotid, femoral, or iliac arteries, or abdominal aorta may or may not be present

• Slow bounding pulse.

• Risk for decreased cardiac output• Risk for decreased tissue perfusion

Gastrointestinal System and Abdomen

• Lack of appetite• Nausea or vomiting during acute event

(increased intracranial pressure [ICP])• Loss of sensation in tongue, cheek, and

throat• Dysphagia

• Chewing and swallowing problems• Distended abdomen• May have absent or diminshed bowel sounds

if neurogenic paralytic ileus present

• Impaired Swallowing• Risk for Imbalanced Nutrition: Less than

Body Requirements• Risk for Constipation

Genitourinary System

• Change in voiding patterns—incontinence, anuria,, retention

• Distended bladder

• Urinary Retention• Risk impaired Urinary Elimination• Sexual dysfunction

Reproductive System

• Sexual Problems • Sexual dysfunction

Musculoskeletal System

• Difficulty with activity due to weakness, loss of sensation, or paralysis (hemiplegia)

• Tires easily• Difficulty resting, pain or muscle twitching• Numbness of arm or leg, especially on one

side of the body

• Altered muscle tone—flaccid or spastic; generalized weakness

• One-sided paralysis• Flaccid shoulder joint

• Impaired physical Mobility• Self-Care Deficit• Unilateral Neglect• Risk for Injury• Risk for fall• Risk for acute pain• Disturbed Sensory Perception• Situational low Self-Esteem• Risk for disturbed Body Image

Neurologic System

• History of TIA• Dizziness or syncope before stroke or

transient during TIA• Severe headache can accompany

intracerebral or subarachnoid hemorrhage• Tingling, numbness, and weakness

commonly reported during TIAs, found in varying degrees in other types of stroke; involved side seems “dead”

• Visual deficits—blurred vision, partial loss of vision (monocular blindness), double vision

• Altered level of consciousness (LOC)• Coma usually presents in the initial stages of

hemorrhagic disturbances.• Altered behavior—lethargy, apathy,

combativeness• Altered cognitive function—memory,

problem-solving,• sequencing• Extremities: Weakness and paralysis

contralateral with all kinds of stroke; unequal hand grasp; diminished deep tendon reflexes

• Impaired verbal [and/or written] Communication

• Disturbed Sensory Perception • Disturbed thought process • Self-Care Deficit• Ineffective Coping• Impaired Swallowing• Unilateral Neglect• Risk for Injury• Risk for fall

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(diplopia), or other disturbances in visual fields

(contralateral)• Facial paralysis or paresis (ipsilateral)• Aphasia: May be expressive (difficulty

producing speech), receptive (difficulty comprehending speech), or global (combination of the two)

• Agnosia• Altered body image awareness, neglect or

denial of contralateral side of body (unilateral neglect); disturbances in perception

• Apraxia• Dysarthria (Difficulty in forming words)• Pupil size and reaction: May be unequal;

dilated and fixed pupil on the ipsilateral side may be present with hemorrhage or herniation

• Nuchal rigidity—common in hemorrhagic stroke

• Seizures—common in hemorrhagic stroke• Problems with vision• Changes in perception of body spatial

orientation (right CVA), neglect• Difficulty seeing objects on left side (right

CVA)• Being unaware of affected side• Inability to recognize familiar objects, colors,

words, faces• Diminished response to heat and cold,

altered bodytemperature regulation

• Swallowing difficulty, inability to meet own nutritional needs

• Loss of gag or cough reflex• Impaired judgment, little concern for safety,

impatience, lack of insight (right CVA)• Speech problems• Inability to communicate• Inappropriate behavior

• Risk for aspiration• Situational low Self-Esteem• Anxiety

REFERENCES: Castillo and Reinoso. (1999) Respiratory Dysfunction Associated with Acute Cerebrovascular Events.

Doenges et. al. (2008). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition.

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Smeltzer et. al. (2010). Brunner and Suddarth’s Medical Surgical Nursing, 12th edition.

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DIAGNOSTIC TESTS

DESCRIPTION RESULT & INTERPRETATION

PROCEDURE NURSING RESPONSIBILITIES

Computed Tomography

CT of the brain is particularly sensitive to the presence of blood. It is especially useful after trauma and when neurologic symptoms suggest a stroke and/or hemorrhage due to embolus, arteriovenous malformation (AVM), angioma, or aneurysm.

Noncontrast CT of the brain is currently the examination of choice for initial imaging of suspected acute stroke. Contrast-enhanced CTs do not consistently visualize low-grade tumors or the full extent of infiltrative neoplasms and associated edema as well as magnetic resonance imaging does.

Normal result/sNo abnormalities.

Abnormal result/sAbscessArteriovenous malformationCerebral aneurysmsCerebral infarctionHemorrhage/hematomaHydrocephalusMeningiomasMultiple sclerosisNeoplasmsVentricular displacementVentricular enlargement

• The patient is assisted to a supine position on the CT scan table.

• A maintenance IV line is initiated.

• The contrast dye is administered by IV injection. Resuscitation and suctioning equipment should be readily available.

• The patient is then placed in the CT scanner.

• Films are made, during which the patient may be asked to hold his or her breath.

Pretest• Explain to the patient the purpose of the test.

Provide any written teaching materials available on the subject. Note that minimal discomfort during the test is due to the venipuncture, and that during injection of the dye, transient sensations including warmth, flushing, a salty taste, and nausea may be experienced. Explain that no movement is allowed during the procedure.

• Check for allergies to iodine, shellfish, or contrast medium dye. Inform the radiologist of such possible allergy and obtain order for an antihistamine and steroid to be administered prior to the test.

• Patients receiving metformin (Glucophage) for Type 2 diabetes mellitus should discontinue the drug 2 days before elective surgery or angiographic exams. This is due to the possible occurrence of lactic acidosis, a potentially fatal complication of biguanide therapy.

• Baseline BUN and creatinine levels are obtained.• Fasting for at least 4 hours is required prior to the

test if contrast dye is to be administered.• The patient should be well hydrated prior to the

beginning of the fasting period.• Obtain a signed informed consent.• For CT of brain, instruct the patient to remove

any metal items from the hair or mouth prior to the procedure.

Post-test• Most allergic reactions to radiopaque dye occur

within 30 minutes of administration of the contrast medium. Observe the patient closely for: respiratory distress, hypotension, edema, hives, rash, tachycardia, and/or laryngeal stridor. Emergency resuscitation equipment must be readily accessible.

• Observe for allergic reaction to the dye for 24

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DIAGNOSTIC TESTS

hours.• Discontinue the IV infusion. Apply pressure at

venipuncture site. Apply dressing, periodically assessing for continued bleeding.

• Resume the patient’s diet. Encourage fluid intake of at least three glasses of liquid to speed the excretion of the dye from the body.

• Monitor urinary output.• Inform the patient that if oral contrast dye was

ingested, diarrhea may occur.• Renal function should be assessed before

metformin is restarted.• Report abnormal findings to the primary care

provider.

Positron Imaging Tomography

Determines the amount of blood flow to the brain.

Reveals how adequately the brain uses blood or nutrients, such as oxygen

.

Normal Result/sNormal patterns of tissue metabolism

Abnormal Result/sAlzheimer’s diseaseCerebrovascular accidentCoronary artery diseaseDementiaEpilepsyHuntington’s choreaMalignant tumorsMetastatic tumorsMigraine headacheParkinson’s diseaseSchizophrenia

• The patient is assisted to a supine position on the scanning table.

• An IV line is initiated.• The patient is moved within

the PET scanner.• The radionuclide is

administered either via the IV line or by inhalation of radioactive gas.

• Images are taken at various times, depending on the particular tissue being scanned.

Pre-test• Explain to the patient the purpose of the test and

the procedure to be followed. Explain to the patient that movement is not allowed during the test. To assist with relaxation and to block any noises which occur during the testing, encourage the patient to listen to an audiotape during the procedure.

• Fasting for an average of 6 hours is required prior to the test. Gum, sugar, and caffeine must be avoided. Water is allowed.

• Instruct patients to refrain from vigorous exercise prior to the exam.

• CT films from previously completed exams need to be available for comparison with PET images.

• Obtain a signed informed consent.• Pre-procedure sedation may be ordered. If used,

it cannot be given until 30 minutes post injection of the radioisotope, since it will affect glucose metabolism of the brain.

• The patient is instructed to void prior to the exam.

Post-test• Assist the patient to slowly rise from the lying

position to avoid postural hypotension. • Discontinue the IV site and check the site for

bleeding. • If a woman who is lactating must have this

procedure, she should not breast feed the infant

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until the radionuclide has been eliminated, possibly for 3 days.

• Although the amount of diagnostic radionuclide excreted in the urine is low, the urine should not be used for any laboratory tests for the time period indicated by the nuclear medicine department.

• Gloves are worn whenever dealing with the urine. • Encourage fluid intake to enhance elimination of

the radionuclide from the body. • Report abnormal findings to the primary care

provider.

Cerebral Angiography

The purposes of cerebral angiography are to detect cerebrovascular abnormalities such as aneurysm or arteriovenous (A-V) malformation, to study vascular displacement due to such problems as tumor or hydrocephalus, and to evaluate the postoperative status of blood vessels. The test involves the introduction of a radiopaque catheter into either the femoral, carotid, or brachial artery, and injecting a contrast medium dye. The most commonly used site is the femoral artery.

Normal Result/sNormal vasculature without occlusion

Abnormal Result/sArterial spasmArteriosclerosisArteriovenous malformationsBrain tumorCerebral aneurysmCerebral fistulaCerebral occlusionCerebral thrombosisIncreased intracranial pressure

• The patient is assisted to a supine position on the examination table.

• A maintenance intravenous line is initiated.

• The area of the puncture site is shaved if necessary, cleansed, and then anesthetized.

• The needle puncture of the artery is made and a guide wire is placed through the needle.

• The catheter is then inserted over the wire and into the artery.

• The radiopaque catheter is advanced into the desired artery. Positioning is monitored via fluoroscopy.

• Once the catheter is in the correct position, contrast dye is injected through the catheter.

• Radiographic films are taken.• After films of satisfactory

quality are obtained, the catheter is removed and pressure held on the puncture site for at least 15 minutes.

• Gloves are worn throughout

Pre-test• Explain to the patient the purpose of the test.

Provide any written teaching materials available on the subject. Note that discomfort involved with this test is primarily due to lying on a hard table for an extended period of time and the needle puncture. Explain that an intense hot flushing may be experienced for 15–30 seconds when the dye is injected.

• Check for allergies to iodine, shellfish, or contrast medium dye. Inform the radiologist of such possible allergy and obtain order for an antihistamine and steroid to be administered prior to the test.

• Baseline laboratory data (CBC, PT, PTT, creatinine) are obtained. Pregnancy test should be obtained on women of childbearing age.

• Note any medications, such as anticoagulants or aspirin, which may prolong bleeding.

• Patients receiving metformin (Glucophage) for Type 2 diabetes mellitus should discontinue the drug 2 days before angiographic exams. This is due to the possible occurrence of lactic acidosis, a potentially fatal complication of biguanide therapy.

• Fasting for at least 8 hours is required prior to the test.

• Obtain a signed informed consent.• Administer any pretest sedation after consent

form is signed.• Assess and document patient’s peripheral pulses

bilaterally prior to the test.

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the procedure. • Perform and document a baseline neurologic assessment.

• For angiography using peripheral puncture sites: Assess and document patient’s peripheral pulses bilaterally prior to the test. Mark the location of the pulses with a marking pen.

Post-Test• Most allergic reactions to radiopaque dye occur

within 30 minutes of administration of the contrast medium. Observe the patient closely for: respiratory distress, hypotension, edema, hives, rash, tachycardia, and/o laryngeal stridor. Emergency resuscitation equipment must be readily accessible.

• A pressure dressing is applied to the puncture site. Check the dressing for bleeding and the area around the puncture site for swelling at frequent intervals.

• For angiography using peripheral puncture sites: The patient is to remain on bedrest for 8–12 hours with the affected extremity immobilized. Maintain pressure on the puncture site with a sandbag.

• Monitor vital signs every 15 minutes for one hour, then every 30 minutes for 2 hours, then every hour for 4 hours, and then every 4 hours.

• Monitor neurological status with each vital sign assessment.

• Monitor urinary output.• Encourage fluid intake to promote dye excretion.• Renal function should be assessed to be

adequate before metformin is restarted.• Report abnormal findings to the primary care

provider.

Transcranial Ultrasonography

Identifies problems with circulation, such as diminished blood flow or presence of atherosclerotic plaques.

Normal Result/sNormal Doppler signal with no evidence of vessel occlusion

Abnormal Result/sArterial occlusionArterial stenosisArteriosclerosisVenous disease

• The patient is assisted to a supine position on the ultrasonography table, with the head turned slightly to one side.

• The patient must remain very still during the exam.

• A coupling agent, such as a water-based gel, is applied

Pre-test• Explain to the patient the purpose of the test.

Provide any written teaching materials available on the subject. Note that there is no discomfort involved with this test.

• Explain the importance of limiting movement during the test to ensure accurate measurements.

• No fasting is required prior to the test.

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Venous occlusion to the area to be evaluated.• A transducer is placed on the

skin and moved as needed to provide clearly emitted sounds.

• The sound waves are transformed into audible sounds which are then printed in graphic form.

Post-test• Cleanse the patient’s skin of remaining coupling

agent.• Report abnormal findings to the primary care

provider.

Lumbar Puncture with Cerebrospinal FluidAnalysis

Measures intracerebral pressure. Collected fluidanalysis assists in diagnosis of cause of CVA.

Normal Result/sCell countWhite blood cells: 0–5 mononuclear cells/μL (0–5 × 106 cells/L SI units)Red blood cells: NoneChloride: 110–125 mEq/L (110–125 mmol/L SI units)Color: Clear, colorlessGlucose: 50–75 mg/dL (2.8–4.2 mmol/L SI units)Pressure: 50–180 mm H20Protein: 15–45 mg/dL (0.15–0.45 g/L SI units)Gamma globulin: 3–12% of total protein

Abnormal Result/sIncreased WBCs Abscess Acute infection Brain infarctionDemyelinating diseaseMeningitis Onset of chronic illnessTumor

Increased RBCs Hemorrhage Traumatic tap

ColorBloody: Subarachnoid, intracerebral, or intraventricular

• The patient is assisted into a side-lying position with the knees drawn up to the abdomen and the chin on the chest. This flexion of the spine provides easy access to the lumbar subarachnoid space.

• Assist the patient in maintaining the proper position by placing one arm around the patient’s knees and the other arm around his or her neck.

• The skin is cleansed and draped. A local anesthetic is administered to the area.

• Ask the patient to report any pain or tingling sensations throughout the procedure which may indicate irritation or puncture of a nerve root.

• The spinal needle is inserted in the midline, usually between the third and fourth lumbar vertebrae.

• The stylet is removed from the needle and a stopcock and manometer are attached to the needle to measure initial CSF pressure.

• A sample of the CSF is collected in a sterile container.

• A final pressure reading is

Pre-test• Explain to the patient the purpose of the test.

Provide any written teaching materials available on the subject. Note that discomfort during the test is due to the injection of the local anesthetic and penetration of the dura mater with the needle

• The patient must remain still while the procedure is performed.

• No fasting is required before the procedure.• Obtain a signed informed consent.

Post-test• Instruct the patient to maintain bedrest for 8

hours with no more than a 30° elevation of the head of the bed. This will help to minimize the occurrence of postlumbar puncture headache.

• Encourage the patient to take in fluids.• Observe the puncture site for swelling and

drainage and assess the movement and sensation to the lower extremities frequently for the first 4 hours after the procedure.

• Report abnormal findings to the primary care provider.

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hemorrhageSpinal cord obstructionTraumatic tap

Cloudy: InfectionProtein in CSF

Orange, yellow, or brown: Erythrocyte breakdown (old blood), elevated protein

Increased GlucoseSystemic Hyperglycemia

Decreased GlucoseBacterial InfectionFungal InfectionMeningitisMumpsPost-subarachnoid HemorrhageSystemic HypoglycemiaTB

Increased PressureHemorrhageInfectionTraumaTumor

Decreased PressureDiabetic ComaShockSpinal Subarachnoid ObstructionSyncope

taken, and the needle is removed.

• A sterile dressing is applied to the puncture site.

• Gloves are worn throughout the procedure.

Electrocardiogram Electrocardiography is the recording of the electrical current generated by the heart. May be doneto rule out cardiac origin as source of

Normal Result/sNormal rate, rhythm, and waveforms

Abnormal Result/sBundle branch blocksCardiac arrest

• The patient is assisted to a supine position. The semi-Fowler’s position may be used for patients with respiratory problems.

• The skin where electrodes are to be applied is cleansed

Pre-test• Explain to the patient the purpose of the test and

the need for electrodes to be attached to the chest and extremities. Note that the test causes no discomfort, but that the patient will need to lie still and not speak during the procedure.

• No fasting is required prior to the test.

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embolus.

Electrical impulses, generated by the heart during its depolarization and repolarization, are detected by monitoring electrodes placed on the body.

Conduction defectsDysrhythmiasElectrolyte imbalancesMyocardial infarctionMyocardial ischemiaPericarditisVentricular hypertrophy

with alcohol. Shaving of the skin may be needed to ensure proper adhesion of the electrodes.

• Electrodes are applied:• One monitoring electrode is

applied to the left arm, right arm, and left leg.

• A grounding electrode is placed on the right leg.

• A total of six electrode positions are used on the chest.

• The patient is to remain still while the recording is completed.

• Many ECG machines are now able to record all 12 leads simultaneously.

Post-test• Remove the electrodes and cleanse the skin of any residual gel or adhesive.• Report abnormal findings to the primary care provider.

Magnetic Resonance Imaging

Demonstrates structural abnormalities and presence of edema, hematoma, ischemia, and infarction.

Normal Result/sNo evidence of pathology

Abnormal Result/sAbscessesArteriovenous malformationAtherosclerotic plaquesAvascular necrosisCerebral infarctionCerebral lesionsDementiaEdemaHemorrhageSeizuresSubarachnoid hemorrhageTumor detection and staging

• The patient is assisted to a supine position on the padded table and moved into the MRI cylinder.

• The patient and MRI staff may communicate via microphone during the procedure.

• As the radio signals are switched on and off and images produced, the patient hears a variety of noises.

Pre-test• Explain to the patient the purpose of the test and

the procedure to be performed. Note that no radiation exposure is involved in this test. Explain that the patient will be moved into a large cylinder for the test and will need to remain completely still during the test. A variety of noises will be heard during the test.

• No fasting is required prior to the test.• Obtain a signed informed consent.• Pre-procedure medication with antianxiety drugs

for those patients with claustrophobia may be needed.

• Remove all metal objects from the body, including medication patches, prior to the test.

• Instruct the patient to void prior to the test.• Sedation may be ordered for patients who are

very young, who are uncooperative, or who are claustrophobic.

Post-test• If sedation was given prior to the exam, ensure

the patient is fully awake prior to ambulation.• Report abnormal findings to the primary care

provider.

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OTHER TESTS

1. Complete Blood Count 2. Platelet and Clotting Studies 3. Erythrocyte Sedimentation Rate 4. Metabolic panel

Various laboratory studies may be done to rule out systemic causes of stroke.

REFERENCES: Doenges et. al. (2008). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition.

Smeltzer et. al. (2010). Brunner and Suddarth’s Medical Surgical Nursing, 12th edition.

Wilson, N. D. (2008) Manual of Laboratory & Diagnostic Tests.

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DRUG INDICATIONS MECHANISM OF ACTION

DOSAGE ADVERSE REACTIONS INTERACTIONS NURSING CONSIDERATIONS

Warfarin (Coumadin)

Classification

Oral Anticoagulant

Treatment of thromboembolic complications of atrial fibrillation with embolization, and cardiac valve replacement.

Interferes with the hepatic synthesis of vitamin K dependent clotting factors (factors II-prothrombin, VII, IX, and X), resulting in their eventual depletion and prolongation of clotting times.

Adults: Initially, 2.5 to 10 mg P.O. or I.V. daily for 2 to 4 days, then adjusted

based on prothrombin time (PT) or International Normalized Ratio (INR). Usual maintenance dosage is 2 to 10 mg P.O. daily.

GI: nausea, vomiting, diarrhea, abdominal cramps, stomatitis, anorexia

GU: hematuria

Hematologic: eosinophilia, bleeding, hemorrhage, agranulocytosis, leukopenia

Hepatic: hepatitis

Skin: rash, dermatitis, urticaria, pruritus, alopecia dermal necrosis

Other: fever, “purple toes” syndrome (bilateral painful, purple lesions on toes and sides of feet), hypersensitivity reaction

Drug-drug. Abciximab, acetaminophen (chronic use), androgens, aspirin, capecitabine, cefamandole, cefoperazone, cefotetan, chloral hydrate, chloramphenicol, clopidogrel, disulfiram, eptifibatide, fluconazole, fluoroquinolones, itraconazole, metronidazole (including vaginal use), nonsteroidal anti-inflammatory drugs, plicamycin, quinidine, quinine, sulfonamides, thrombolytics, ticlopidine, tirofiban, valproic acid, zafirlukast: increased response to warfarin, greater risk of bleeding

Barbiturates, hormonal contraceptives containing estrogen: decreased anti coagulant effect

Drug-diagnostic tests. Alanine aminotransferase, aspartate aminotransferase,

INR: increased values

Partial thromboplastin

• Monitor PT, INR, and liver function tests.

• Watch for signs and symptoms of bleeding and hepatitis.

• Explain therapy to patient. Stress importance of adhering to schedule for laboratory tests.

• Instruct patient to promptly report unusual bleeding or bruising.

• Caution patient to consult prescriber before taking over-the-counter prepa- rations or herbs.

• Advise patient to inform all other health care providers (including dentist) that he’s taking warfarin.

• Tell patient not to vary his intake of foods high in vitamin K (such as leafy green vegetables, fish, pork, green tea, and tomatoes), to avoid alterations in drug’s anticoagulant effect.

• Instruct females of childbearingage to report pregnancy immediately.

• Stress importance of avoiding contact sports and other activities that could cause injury and bleeding.

• Caution patient to avoid alcohol during therapy.

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MEDICAL MANAGEMENT: Pharmacology

time, PT: pro- longed

Drug-food. Vitamin K–rich foods (large amounts): antagonism of anticoagulant effect

Drug-herbs. Angelica: prolonged PT Anise, arnica, asafetida, bromelain, chamomile, clove, danshen, devil’s claw, dong quai, fenugreek, feverfew, garlic,

ginger, ginkgo, ginseng, horse chestnut, licorice, meadowsweet, motherwort, onion, papain, parsley, passionflower, quassia, red clover, Reishi mushroom,

rue, sweet clover, turmeric, white willow

others: increased risk of bleeding Coenzyme Q10, green tea, St. John’s wort: decreased anticoagulant effect

Drug-behaviors. Alcohol use: enhanced warfarin activity

Aspirin (Aspergum)

ClassificationAnti-inflammatory, antiplatelet, anti-pyretic, nonopioid analgesic

To reduce the risk of recurrent transientischemic attacks or stroke in men

Aspirin inhibits platelet aggregation by interfering with production of thromboxane A2, a substance that stimulates platelet aggregation. Aspirin acts on the heat regulating center in the hypothalamus and causes peripheral vasodilation,

CHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASETABLETS, ENTERIC-COATED TABLETS,SOLUTION, TABLETS, TIMED-RELEASE TABLETS,SUPPOSITORIESAdults. 650 mg b.i.d.

CNS: Confusion, CNS depressionEENT: Hearing loss, tinnitusGI: Diarrhea, GI bleeding, heartburn, hepatotoxicity, nausea, stomach pain, vomitingHEME: Decreased blood iron level, leukopenia, prolonged bleeding time, shortened life span of RBCs, thrombocytopenia

Drug-drugACE inhibitors: Decreased antihypertensive effectactivated charcoal: Decreased aspirin absorptionantacids, urine alkalinizers: Decreased aspirin effectivenessanticoagulants: Increased risk of bleeding;

• Don’t crush timed-release or controlledrelease aspirin tablets unless directed.

• Ask about tinnitus. This reaction usually occurs when blood aspirin level reaches or exceeds maximum for therapeutic effect.

• WARNING Advise parents not to give aspirin to a child or adolescent with

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diaphoresis,and heat loss.

or 325 mg q.i.d. SKIN: Ecchymosis, rash, urticariaOther: Angioedema, Reye’s syndrome, salicylism (dizziness, tinnitus, difficulty hearing, vomiting, diarrhea, confusion, CNS depression, diaphoresis, headache, hyperventilation, and lassitude) with regular use of large doses

prolonged bleeding timecarbonic anhydrase inhibitors: Salicylismcorticosteroids: Increased excretion and decreased blood level of aspirinheparin: Increased risk of bleedingibuprofen: Possibly reduced cardioprotective and stroke preventive effects of aspirinmethotrexate: Increased blood level and decreased excretion of methotrexate, causing toxicitynizatidine: Increased blood aspirin levelNSAIDs: Possibly decreased blood NSAID level and increased risk of adverse GI effectssulfonylureas: Possibly enhanced effect of sulfonylureas with large doses of aspirinurine acidifiers (such as ammonium chloride,ascorbic acid): Decreased aspirin excretionvancomycin: Increased risk of ototoxicityActivitiesalcohol use: Increased risk of ulcers

chickenpox or flu symptoms because of risk of Reye’s syndrome (rare life-threatening reaction characterized by vomiting, lethargy, belligerence, delirium, and coma). Tell them to consult prescriber for alternative drugs.

• Advise adult patient taking low-dose aspirin not to also take ibuprofen because it may reduce the cardioprotective and stroke preventive effects of aspirin.

• Instruct patient to take aspirin with food or after meals because it may cause GI upset if taken on an empty stomach.

• Advise patient with tartrazine allergy not to take aspirin.

• Tell patient to consult prescriber before taking aspirin with any prescription drug for blood disorder, diabetes, gout, or arthritis.

• Tell patient not to use aspirin if it has a strong vinegar-like odor.

Alteplase (Activase rt-PA)

ClassificationThrombolytic

Acute Ischemic Stroke

Binds to fibrin in a thrombus and converts trapped plasminogen to plasmin. Plasminbreaks down fibrin, fibrinogen, and otherclotting factors, which dissolves the thrombus.

Acute Ischemic StrokeTo avoid acute bleeding complications,treatment for acute ischemic stroke must begin within 3 hr after onset of stroke symptoms and only

CNS: Cerebral edema, cerebral herniation,fever, seizure, strokeCV: Arrhythmias (including bradycardia and electromechanical dissociation), cardiac arrest, cardiac tamponade, cardiogenicshock, cholesterol embolism,

Drug-Drugdrugs that alter platelet function, such as abciximab, acetylsalicylic acid, and dipyridamole;heparin; vitamin K antagonists:Increased risk of bleeding

• WARNING To avoid acute bleeding complications, treatment for acute ischemic stroke must begin within 3 hr after onset of stroke symptoms and only after computed tomography or other diagnostic imaging method excludes

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after computed tomographyor other diagnostic imaging method excludes intracranial hemorrhage.I.V. INFUSIONAdults. 0.9 mg/kg infused over 60 min,with 10% of total dose given as bolus overfirst min. Maximum: 90 mg.

coronarythrombolysis, heart failure, hypotension, mitral insufficiency, myocardial reinfarction or rupture, pericardial effusion, pericarditis,venous thrombosis and embolismEENT: Epistaxis, gingival bleeding, laryngeal edemaGI: GI bleeding, nausea, retroperitoneal bleeding, vomitingGU: GU bleedingRESP: Pleural effusion, pulmonary edema, pulmonary reembolizationSKIN: Bleeding at puncture sites, ecchymosis, rash, urticariaOther: Anaphylaxis

intracranial hemorrhage.• Immediately before use

reconstitute alteplase with sterile water for injection only.

• Swirl gently to dissolve powder; don’t shake.

• Monitor patient for bleeding, especially at arterial puncture sites.

• Monitor blood pressure and heart rate and rhythm frequently during and after therapy.

• WARNING Alteplase therapy may cause arrhythmias from sudden reperfusion of the myocardium.Monitor continuous

• ECG for arrhythmias during drug therapy.

• Minimize bleeding from noncompressible sites by avoiding internal jugular and subclavian venous puncture sites.

• Discontinue alteplase immediately if serious bleeding occurs.

• After administering alteplase, apply pressure for at least 30 minutes, followed by a pressure dressing.

• Store reconstituted solution at room temperature (about 86° F [30° C]) or refrigerated (36° to 46° F [2.2° to 7.7° C).

Dipyridamole (Persantine)

Classification Coronary vasodilator,diagnostic aid, platelet

To prevent thromboemboliccomplications of cardiac

May increase the intraplatelet level ofadenosine, which causes coronary vasodilation and inhibits platelet aggregation.Dipyridamole also may increase the

TABLETSAdults. 75 to 100 mg q.i.d. with coumarin or indanedione derivative anticoagulant.

CNS: Dizziness, headacheCV: Angina, arrhythmias, ECG changes (specifically, ST-segment and T-wavechanges)GI: Abdominal pain, diarrhea, nausea, vomitingRESP: Dyspnea

adenosine: Potentiated effects of adenosinecefamandole, cefoperazone, cefotetan, plicamycin,valproic acid: Possibly hypoprothrombinemiaand increased risk of

• Protect I.V. form of dipyridamole from direct light and freezing.

• Monitor blood pressure, pulse rate and rhythm, and breath sounds every 10 to 15 minutes during I.V. infusion.

• Keep parenteral

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aggregationinhibitor

intraplatelet level of cyclic adenosine monophosphate (cAMP) and may inhibit formation of the potent platelet activator stimulant thromboxane A2, which decreases platelet activation. Vasodilation and increased blood flow occur preferentially innondiseased coronary vessels, which resultsin redistribution of blood away from significantly diseased vessels. These changes in perfusion are observed during thallium imaging studies.

SKIN: Flushing, pruritus, rash bleedingheparin, NSAIDs, thrombolytics: Possibly increased risk of bleedingtheophylline: Reversal of coronary vasodilation caused by dipyridamole, possibly falsenegative thallium imaging result

aminophylline available to relieve adverse reactions to dipyridamole infusion.

• At therapeutic doses, expect adverse reactions to be minimal and transient. They typically resolve with long-term use.

Clopidogrel (Plavix)

ClassificationPlatelet aggregation

To reduce atherosclerotic events, such as stroke and MI, in patients with atherosclerosisdocumented by recent stroke, MI, or peripheral artery disease

Binds to adenosine diphosphate (ADP)receptors on the surface of activated platelets. This action blocks ADP, whichdeactivates nearby glycoprotein IIb/IIIareceptors and prevents fibrinogen from attaching to receptors. Without fibrinogen, platelets can’t aggregate and form

TABLETSAdults. Loading dose: 300 mg. Maintenance: 75 mg daily.

CNS: Confusion, depression, dizziness, fatigue, hallucinations, headacheCV: Chest pain, edema, hypercholesterolemia, hypertension, hypotension, vasculitisEENT: Altered taste; conjunctival, ocular, or retinal bleeding; epistaxis; rhinitis; taste disordersGI: Abdominal pain; acute liver failure; colitis; diarrhea; duodenal, gastric, or peptic ulcer; elevated liver function test results; gastritis; indigestion; nausea; noninfectioushepatitis; pancreatitisGU: Elevated serum creatinine level, glomerulopathy, UTIHEME: Agranulocytosis, aplastic anemia, neutropenia, pancytopenia, prolonged bleeding time,

Drug-DrugDRUGSaspirin: Increased risk of bleeding CYP2C19 inhibitors, such as cimetidine, esomeprazole, etravirine, felbamate, fluconazole, fluoxetine, fluvoxamine, ketoconazole,omeprazole, ticlopidine, voriconazole: Decreased plasma clopidogrel level, decreased platelet inhibition fluvastatin, phenytoin, tamoxifen, tolbutamide, torsemide: Interference with metabolismof these drugsNSAIDs: Increased risk of GI bleeding, interference with NSAID metabolismwarfarin: Prolonged bleeding time,

• Avoid clopidogrel in patients who have a genetic variation in CYP2C19 or are receiving CYP2C19 inhibitors. Platelet inhibition may decline, increasing the risk of adverse cardiovascular effects after MI.

• Use clopidogrel cautiously in patients with severe hepatic or renal disease, risk of bleeding from trauma or surgery, or conditions that predispose to bleeding (such as peptic ulcer disease or thrombotic thrombocytopenic purpura).

• In patient with acute coronary syndrome, expect to give aspirin with clopidogrel.

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thrombocytopenic purpura,thrombotic thrombocytopenic purpura,unusual bleeding or bruisingMS: Arthralgia, back pain, myalgiaRESP: Bronchitis, bronchospasm, cough, dyspnea, interstitial pneumonitis, upper respiratory tract infection SKIN: Erythema multiforme, lichen planus, pruritus, purpura, rash, Stevens-Johnson syndrome, toxic epidermal necrolysisOther: Anaphylaxis, angioedema, flulike symptoms, serum sickness

interference with warfarin metabolism

• WARNING Clopidogrel prolongs bleeding time; expect to stop it 5 days before elective surgery.

• Obtain blood cell count, as ordered, whenever signs and symptoms suggest a hematologic problem.

• Monitor patient who takes aspirin closely because risk of bleeding is increased.

Ticlopidine (Ticlid)

ClassificationAntithrombotic, platelet aggregation inhibitor

To reduce the risk of initial thrombotic stroke in patients who have experienced transient ischemic attack, to reduce the risk of recurrent stroke in patients who have previously experienced thrombotic stroke

Normally, platelets don’t adhere to bloodv vessel walls. However, when a thrombotic stroke or other disorder damages blood vessel walls, platelets are activated and adhere within seconds. Once activated, platelets release adenosine diphosphate (ADP). This causes fibrinogen to bind to glycoprotein IIb/IIIa (GP IIb/IIIa) receptors on the surface of activated platelets and connect with other activated platelets. Then a thrombus forms. Ticlopidine inhibits the release of ADP from activated platelets, which prevents fibrinogen from binding to GP

TABLETSAdults. 250 mg b.i.d.

CNS: DizzinessCV: Hypercholesterolemia, vasculitisEENT: TinnitusGI: Abdominal pain, anorexia, diarrhea, elevated liver function test results, flatulence, indigestion, nausea, vomitingHEME: Agranulocytosis, aplastic anemia, hemolysis, hemolytic anemia, neutropenia, pancytopenia, thrombocytopenia, thrombotic thrombocytopenia, thromboticthrombocytopenic purpuraSKIN: Pruritus, purpura, rashOther: Hyponatremia, serum sickness like reaction

Drug-drugaluminum- and magnesium-containing antacids: Possibly decreased peak blood ticlopidine levelantineoplastics, antithymocyte globulin, heparin, NSAIDs, oral anticoagulants, platelet aggregation inhibitors, salicylates, strontium-89 chloride, thrombolytics: Increased risk of bleedingcimetidine: Reduced clearance of ticlopidine, increased risk of adverse reactionscyclosporine, digoxin: Decreased blood leveland possibly reduced effects of these drugsporfimer: Decreased effectiveness of porfimer photodynamic therapyxanthines (aminophylline, oxytriphylline,

• Give ticlopidine with food to maximize GI absorption and minimize any GI distress.

• Avoid I.M. injections of other drugs because excessive bleeding, bruising, or hematoma may occur.

• During first 3 months of therapy, monitor CBC every 2 weeks, as ordered (more frequently in patients with depressed Neutrophil count).

• Be aware that ticlopidine therapy typically is used for patients with stroke or an increased risk of stroke who can’t tolerate aspirin because of the risk of neutropenia or agranulocytosis.

• WARNING Be aware that ticlopidine therapy irreversibly affects platelet aggregation. Expect prescriber to

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IIb/IIIa receptors on the surface of activated platelets, as shown below. Thisaction prevents platelets from aggregating to form a thrombus, which prevents thrombosis of an implanted stent or recurrence of stroke.

theophylline): Decreased theophylline clearance, increased risk of toxicity

discontinue drug 10 to 14 days before surgical procedures to prevent uncontrolled bleeding.

• Monitor serum cholesterol level during first month of ticlopidine therapy for expected increase. Hypercholesterolemia may persist for duration of treatment.

Atorvastatin calcium(Lipitor)

Classification Lipid-lowering Agent (statins)

Prevention of stroke and myocardial infarction in patients with type 2diabetes who have multiple riskfactors for CHD but without clinicallyevident CHD;Adjunct to diet for controllingLDL, total cholesterol, apo-lipoproteinB, and triglyceride levels and to in-crease HDL levels in patients with pri-mary hypercholesterolemia and mixeddyslipidemia; primary dysbetalipoproteinemia in patients unresponsive todiet alone; adjunct to diet to reduceelevated triglyceride levels

Inhibits HMG-CoA reductase, whichcatalyzes first step in cholesterol syn-thesis; this action reduces concentra-tions of serum cholesterol and low-density lipoproteins (LDLs), linked toincreased risk of coronary artery dis-ease (CAD). Also moderately increasesconcentration of high-density lipoproteins (HDLs), associated with decreased risk of CAD.

Adults: Initially, 10 mg P.O. daily; in-crease to 80 mg P.O. daily if needed.

CNS: amnesia, abnormal dreams,emotional lability, headache, hyperactivity, poor coordination, malaise,paresthesia, peripheral neuropathy,drowsiness, syncope, weaknessCV: orthostatic hypotension, palpitations, phlebitis, vasodilation, arrhythmiasEENT: amblyopia, altered refraction,glaucoma, eye hemorrhage, dry eyes,hearing loss, tinnitus, epistaxis, sinusitis,pharyngitisGI: nausea, vomiting, diarrhea, constipation, abdominal cramps, abdominalor biliary pain, colitis, indigestion, dyspepsia, flatulence, stomach ulcers, gastroenteritis, melena, tenesmus, glossitis, mouth sores, dry mouth, dysphagia, esophagitis, pancreatitis, rectal hemorrhageGU: hematuria, nocturia, dysuria, urinary frequency or urgency, urinary retention, cystitis, nephritis, renal calculi, abnormal ejaculation, decreased libido, erectile dysfunction, epididymitisHematologic: anemia,

Drug-drug. Antacids, colestipol: decreased atorvastatin blood levelAzole antifungals, cyclosporine, erythromycin, fibric acid derivatives, niacin,other HMG-CoA inhibitors: increasedrisk of myopathyDigoxin: increased digoxin level,greater risk of toxicityHormonal contraceptives: increased estrogen levelDrug-diagnostic tests. Alanine amino-transferase, aspartate aminotransferase,creatine kinase: increased levelsDrug-food. Grapefruit juice: increased drug blood level, greater risk of adverse effectsDrug-herbs. Red yeast rice: increasedrisk of adverse effects

• Monitor patient for signs and symptoms of allergic response.

• Evaluate for muscle weakness (a symptom of myositis and possibly rhabdomyolysis).

• Monitor liver function test results and blood lipid levels.

• Tell patient he may take drug with or,without food.

• Advise patient to immediately report allergic response, irregular heartbeats, unusual bruising or bleeding,unusual tiredness, yellowing of skin or eyes, or muscle weakness.

• Instruct patient to avoid grapefruit juice during therapy.

• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, alertness, and vision.

• Advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.

• Inform patient taking hormonal contraceptives

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thrombocytopeniaHepatic: jaundice, hepatic failure,hepatitisMetabolic: hyperglycemia, hypoglycemiaMusculoskeletal: bursitis, joint pain,back pain, leg cramps, gout, musclepain or aches, myositis, myastheniagravis, neck rigidity, torticollis, rhabdomyolysisRespiratory: dyspnea, pneumonia,bronchitisSkin: alopecia, acne, contact dermatitis, eczema, dry skin, pruritus, rash, urticaria, skin ulcers, seborrhea, photosensitivity, diaphoresisOther: taste loss, gingival bleeding,fever, facial paralysis, facial or generalized edema, flulike symptoms, infection, appetite changes, weight gain, allergic reaction

that drug increases estrogen levels. Instruct her to tell all prescribers she’s taking drug.

Vitamin (AquaMEPHYTON)

ClassificationVitamins

Hypoprothrombinemia secondary to vitamin K malabsorption, drug therapy, or excessive vitamin A dosage; hypoprothrombinemia secondary to effect of oral anticoagulants; prevention of hemorrhagic disease of newborn prevention of hypoprothrombonemia related to vitamin K deficiency for long-term

An antihemorrhagic actor that promotes hepatic formation of active prothrombin.

I.M. INJECTIONAdults. 5 to 10 mg/wk.Children. 2 to 5 mg/wk.

dizziness, transient hypotension after IV administration, rapid and weak pulse, diaphoresis,flushing, erythema, pain, swelling and hematoma at injection site.

Warfarin (Coumadin: decrease the effectiveness of warfarin (Coumadin).

• Be aware that severe adverse reactions, including anaphylaxis, cardiac and respiratory arrest, hypersensitivity, and shock, may occur during or immediately after I.M. or I.V. administration of vitamin K1, even if it’s diluted to avoid rapid infusion. Administer vitamin by SubQ route whenever possible.

• If vitamin K1 must be administered I.V., do not exceed rate of 1 mg/min, as prescribed.

• Be aware that some vitamin K1 solutions contain benzyl

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parenteral nutrition; prevention of hypoprothrombinemia in infants receiving less than 0.1 mg/liter vitamin K in breast milk or milk substitute.

alcohol.Don’t administer these solutions to neonates or immature infants because of a risk of fatal toxic syndrome, which may include CNS, respiratory, circulatory, and renal impairment and metabolic acidosis.

• Take precautions to protect vitamin K1 solution from exposure to light becauseit’s light sensitive.

Captopril(Capoten)

Classification Angiotensin-converting enzyme (ACE) inhibitor

Anti-hypertensive

Hypertension Prevents conversion of angiotensin I to angiotensin II, which leads to de-creased vasoconstriction and, ultimately, to lower blood pressure. Also decreases blood pressure by increasingplasma renin secretion from kidney and reducing aldosterone secretion from adrenal cortex. Decreased aldosterone secretion prevents sodium andwater retention.

Adults: 12.5 to 25 mg P.O. two to three times daily; may be increased up to150/mg/day at 1to 2-week intervals.Usual dosage is 50 mg t.i.d. If patient isreceiving diuretics, start with 6.25 to12.5 mg P.O. two to three times daily. Ifblood pressure isn’t adequately controlled after 1 to 2 weeks, add diuretic, as prescribed. If further blood pressure decrease is needed, dosage may beraised to 150 mg P.O. t.i.d. while patient continues on diuretic. Maximumdosage is 450 mg/day.

CNS: headache, dizziness, drowsiness,fatigue, weakness, insomnia CV: angina pectoris, tachycardia, hy-potensionEENT: sinusitisGI: nausea, diarrhea, anorexiaGU: proteinuria, erectile dysfunction,decreased libido, gynecomastia, renal failureHematologic: anemia, agranulocytosis, leukopenia, pancytopenia, thrombocytopeniaMetabolic: hyperkalemiaRespiratory: cough, asthma, bronchitis, dyspnea, eosinophilic pneumonitisSkin: rash, angioedemaOther: altered taste, fever

Drug-drug. Allopurinol: increased riskof hypersensitivity reactionAntacids: decreased captopril absorptionAntihypertensives, general anestheticsthat lower blood pressure, nitrates,phenothiazines: additive hypotensionCyclosporine: hyperkalemiaDigoxin, lithium: increased blood levelsof these drugs, increased risk of toxicityEpoetin alfa: additive hyperkalemiaIndomethacin: reduced antihypertensive effect of captoprilNonsteroidal anti-inflammatory drugs:decreased antihypertensive responsePotassium-sparing diuretics, potassiumsupplements: hyperkalemiaProbenecid: decreased elimination andincreased blood level of captopril

• Monitor for sudden blood pressure drop within 3 hours of initial dose if patient is receiving concurrent diuretics and on a low-sodium diet.

• Monitor hematologic, kidney, an liver function test results.

• Check for proteinuria monthly and after first 9 months of therapy.

• Tell patient to take drug 1 hour before meals on empty stomach.

• Advise patient to report fever, rash, sore throat, mouth sores, fast or irregular heartbeat, chest pain, or cough.

• Inform patient that dizziness, fainting, and lightheadedness usually disappear once his body adjusts to drug.

• Tell patient his ability to taste may decrease during first 2 to 3 months of therapy.

• Caution patient to avoid over-the- counter medications unless approved by prescriber.

• As appropriate, review all other significant and life-threatening adverse

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Drug-diagnostic tests. Alanine amino- transferase, alkaline phosphatase, aspartate aminotransferase, bilirubin, blood urea nitrogen, creatinine, potassium: increased levelsGranulocytes, hemoglobin, platelets, red blood cells, sodium, white blood cells:decreased levelsUrine acetone: false-positive resultDrug-food. Any food: decreased captopril absorptionSalt substitutes containing potassium:hyperkalemiaDrug-herbs. Capsaicin, yohimbine: coughDrug-behaviors. Acute alcohol ingestion: additive hypotension

reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.

Mannitol (Osmitrol)

Classification

To reduce intracranial or intraocular pressure

Elevates plasma osmolality, causing water to flow from tissues, such as brain and eyes, and from CSF, into extracellular fluid, thereby decreasing intracranial and intraocular pressure. As an osmotic diuretic, mannitol increases the osmolarity of glomerular filtrate, which decreases water reabsorption. This leads to increased excretion of water, sodium, chloride, and toxic substances. As an irrigant, mannitol

I.V. INFUSIONAdults and adolescents.  0.25 to 2 g/kg as 15% to 25% solution given over 30 to 60 min. If used before eye surgery, 1.5 to 2 g/kg 60 to 90 min before procedure.  Maximum: 6 g/kg daily.DOSAGE ADJUSTMENTFor small or debilitated patients, dosage reduced to 0.5 g/kg.

CNS: Chills, dizziness, fever, headache, seizuresCV: Chest pain, heart failure, hypertension, tachycardia, thrombophlebitisEENT: Blurred vision, dry mouth, rhinitisGI: Diarrhea, nausea, thirst, vomitingGU: Polyuria, urine retentionRESP: Pulmonary edemaSKIN: Extravasation with edema and tissue necrosis, rash, urticariaOther: Dehydration, hyperkalemia, hypernatremia, hypervolemia, hypokalemia, hyponatremia (dilutional), metabolic acidosis, water intoxication

Drug-drug. digoxin: Increased risk of digitalis toxicity from hypokalemiadiuretics: Possibly increased therapeutic effects of mannitol

• If crystals form in mannitol solution exposed to low temperature, place solution in hot-water bath to redissolve crystals.

• Use a 5-micron in-line filter when administering drug solution of 15% or greater.

• During I.V. infusion of mannitol, monitor vital signs, central venous pressure, and fluid intake and output every hour. Measure urine output with indwelling urinary catheter, as appropriate.

• Check weight and monitor BUN and serum creatinine electrolyte levels daily.

• Provide frequent mouth

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minimizes the hemolytic effects of water used as an irrigant and reduces the movement of hemolyzed blood from the urethra to the systemic circulation, which prevents hemoglobinemia and serious renal complications.

care to relieve thirst and dry mouth.

Furosemide (Lasix)

Classification Antihypertensive, diuretic

To manage mild to moderate hypertension, as adjunct to treat acute pulmonary edema and hypertensive crisis

Inhibits sodium and water reabsorption in the loop of Henle and increases urine formation. As the body’s plasma volume decreases, aldosterone production increases, which promotes sodium reabsorption and the loss of potassium and hydrogen ions. Furosemide also increases the excretion of calcium, magnesium, bicarbonate, ammonium, and phosphate. By reducing intracellular and extracellular fluid volume, the drug reduces blood pressure and decreases cardiac output. Over time, cardiac output returns to normal.

ORAL SOLUTION, TABLETSAdults. Initial: 40 mg b.i.d., adjusted until desired response occurs.  Maximum: 600 mg daily.I.V. INFUSION OR INJECTIONAdults with normal renal function. 40 to 80 mg as a single dose over several minutes.Adults with acute renal failure or pulmonary edema. 100 to 200 mg as a single dose over several minutes.DOSAGE ADJUSTMENTFor patients with acute pulmonary edema without hypertensive crisis, dosage reduced to 40 mg followed by 80 mg 1 hr later if therapeutic response doesn’t occur.

CNS: Dizziness, fever, headache, paresthesia, restlessness, vertigo, weaknessCV: Orthostatic hypotension, shock, thromboembolism, thrombophlebitisEENT: Blurred vision, oral irritation, ototoxicity, stomatitis, tinnitus, transient hearing loss (rapid I.V. injection), yellow visionENDO: HyperglycemiaGI: Abdominal cramps, anorexia, constipation, diarrhea, gastric irritation, hepatocellular insufficiency, indigestion, jaundice, nausea, pancreatitis, vomitingGU: Bladder spasms, glycosuriaHEME: Agranulocytosis (rare), anemia, aplastic anemia (rare), azotemia, hemolytic anemia, leukopenia, thrombocytopeniaMS: Muscle spasmsSKIN: Bullous pemphigoid, erythema multiforme, exfoliative dermatitis, photosensitivity, pruritus, purpura, rash, urticariaOther: Allergic reaction (interstitial nephritis, necrotizing vasculitis, systemic vasculitis), dehydration, hyperuricemia, hypochloremia,

Drug-drug.ACE inhibitors: Possibly first-dose hypotensionaminoglycosides, cisplatin:  Increased risk of ototoxicityamiodarone: Increased risk of arrhythmias from hypokalemiachloral hydrate: Possibly diaphoresis, hot flashes, and hypertensiondigoxin: Increased risk of digitalis toxicity related to hypokalemiainsulin, oral antidiabetic drugs: Increased blood glucose levellithium: Increased risk of lithium toxicityNSAIDs: Possibly decreased diuresisphenytoin, probenecid: Possibly decreased therapeutic effects of furosemidepropranolol: Possibly increased blood propranolol levelthiazide diuretics: Possibly profound dieresis and electrolyte imbalancesACTIVITIESalcohol use: Possibly increased hypotensive and diuretic effects of

• WARNING Use furosemide cautiously in patients with advanced hepatic cirrhosis, especially those who also have a history of electrolyte imbalance or hepatic encephalopathy; drug may lead to lethal hepatic coma.

• Obtain patient’s weight before and periodically during furosemide therapy to monitor fluid loss.

• For once-a-day dosing, give drug in the morning so patient’s sleep won’t be interrupted by increased need to urinate.

• Prepare drug for infusion with normal saline solution, lactated Ringer’s solution, or D5W.

• Administer drug slowly I.V. over 1 to 2 minutes to prevent ototoxicity.

• Expect patient to have periodic hearing tests during prolonged or high-dose I.V. therapy.

• •Monitor blood pressure and hepatic and renal function as well as BUN, blood glucose, and serum

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hypokalemia, hyponatremia, hypovolemia

furosemide creatinine, electrolyte, and uric acid levels, as appropriate.

• Be aware that elderly patients are more susceptible to hypotensive and electrolytealtering effects and thus are at greater risk for shock and thromboembolism.

• If patient is at high risk for hypokalemia, give potassium supplements along with furosemide, as prescribed.

• Expect to discontinue furosemide at maximum dosage if oliguria persists for more than 24 hours.

• Be aware that furosemide may worsen left ventricular hypertrophy and adversely affect glucose tolerance and lipid metabolism.

• Notify prescriber if patient experiences hearing loss, vertigo, or ringing, buzzing, or sense of fullness in her ears. Drug may need to be discontinued.

REFERENCE: Learning, Jones and Barlett (2011). Nurse’s Drug Handbook, 10th edition.

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PRIORITY: Number 1Nursing Diagnosis: Ineffective cerebral tissue perfusionMay be related to: Interruption of blood flow—occlusive disorder, hemorrhage; cerebral vasospasm, cerebral edemaCause Analysis: Cerebrovascular disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is

disrupted. In ischemic stroke, significant hypoperfusion occur because of vascular occlusion. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1896)

Cues Objectives Nursing Interventions Rationale

Objective Cues Altered LOC; memory loss Changes in motor or

sensory responses; restlessness

Sensory, language, intellectual, and emotional deficits

Changes in vital signs

Short-term ObjectiveWithin 8 hours of providing nursing interventions, the client will:• Demonstrate stable vital signs

and absence of signs of increased ICP.

• Display no further deterioration or recurrence of deficits.

Long-term ObjectiveWithin 3 days of providing nursing interventions, the patient will:• Maintain usual or improved

LOC, cognition, and motor and sensory function.

Independent

Determine factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for ICP.

Monitor and document neurological status frequently and compare with baseline. (Refer to CP: Craniocerebral Trauma—Acute Rehabilitative Phase, ND: ineffective cerebral tissue Perfusion for complete neurological evaluation.

Monitor vital signs noting:

Hypertension or hypotension; compare blood pressure (BP) readings in both arms

Heart rate and rhythm; auscultate for murmurs

Respirations, noting patterns and rhythm—periods of apnea after hyperventilation, Cheyne-Stokes respiration

Evaluate pupils, noting size, shape, equality, and light reactivity.

Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. If the stroke is evolving, client can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence.

Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage. May also reveal TIA, which may resolve with no further symptoms or may precede thrombotic CVA.

Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor. Hypotension may follow stroke because of circulatory collapse.

Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA, for example, stroke after MI or from valve dysfunction.

Irregularities can suggest location of cerebral insult or increased ICP and need for further intervention, including possible respiratory support. (Refer to CP: Craniocerebral Trauma—Acute Rehabilitative Phase, ND: risk for ineffective Breathing Pattern.)

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NURSING CARE PLANS

Document changes in vision, such as reports of blurred vision and alterations in visual field or depth perception.

Assess higher functions, including speech, if client is alert. (Refer to ND: impaired verbal [and/or written] Communication.)

Position with head slightly elevated and in neutral position.

Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures.

Prevent straining at stool or holding breath.

Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity.

Collaborative

Administer supplemental oxygen, as indicated.

Administer medications, as indicated, for example

Intravenous thrombolytics, such as tissue plasminogen activator (tPA), alteplase (Activase), and recombinant prourokinase (Prourokinase)

Anticoagulants, such as warfarin sodium (Coumadin); lowmolecular- weight heparin, for example, enoxaparin (Lovenox) and dalteparin (Fragmin); and direct thrombin inhibitor, such as ximelagatran (Exanta)

Antiplatelet agents, such as aspirin (ASA), aspirin with extended-release dipyridamole (Aggrenox), ticlopidine (Ticlid), and clopidogrel (Plavix)

Antihypertensives

Peripheral vasodilators, such as cyclandelate (Cyclospasmol), papaverine (Pavabid), and isoxsuprine (Vasodilan)

Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves.

Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.

Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate increased ICP.

Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion.

Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent recurrence of bleeding, in the case of hemorrhagic stroke.

Valsalva’s maneuver increases ICP and potentiates risk of bleeding.

Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP or reflect location and severity of cerebral injury, requiring further evaluation and intervention.

Reduces hypoxemia.

As the only proven therapy for early acute ischemic stroke, tPA is useful in minimizing the size of the infarcted area by opening blocked vessels that are occluded with clot. Treatment must be started within 3 hours of initial symptoms to improve outcomes. Note: These agents are contraindicated in several instances—intracranial hemorrhage as diagnosed by CT scan, recent intracranial surgery, serious head trauma, and uncontrolled hypertension.

May be used to improve cerebral blood flow and prevent further clotting when embolus or thrombosis is the problem.

Antiplatelet agents are used following an ischemic stroke or TIA.

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Neuroprotective agents, such as calcium channel blockers, excitatory amino acid inhibitors, and gangliosides

Phenytoin (Dilantin) and Phenobarbital.

Prepare for surgery, as appropriate—carotid endarterectomy, microvascular bypass, and cerebral angioplasty.

Monitor laboratory studies as indicated, such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level.

Preexisting or chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage during an evolving stroke. Transient hypertension often occurs during acute stroke and usually resolves without therapeutic intervention.

Used to improve collateral circulation or decrease vasospasm.

These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical events—influx of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acid—to limit ischemic injury.

May be used to control seizures and for sedative action. Note: Phenobarbital enhances action of antiepileptics.

May be necessary to resolve hemorrhagic situation and reduce neurological symptoms and risk of recurrent stroke.

Provides information about effectiveness and therapeutic level of anticoagulants when used.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p242-244

PRIORITY: Number 2Nursing Diagnosis: Impaired physical MobilityMay be related to: Neuromuscular involvement: weakness, paresthesia; flaccid, hypotonic paralysis (initially); spastic paralysis, Perceptual or cognitive impairmentCause Analysis: A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary

motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1897)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Inability to purposefully move within the physical environment

Impaired coordination Limited range of motion

(ROM), Decreased muscle strength

and control

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

• Maintain or increase strength and function of affected or compensatory body part.

• Maintain optimal position of function as evidenced by absence of contractures and footdrop.

Long-term Objective

Within 3 days of providing nursing interventions, the client

Independent

PositioningAssess functional ability and extent of impairment initially and

on a regular basis. Classify according to a 0 to 4 scale. (Refer to CP: Craniocerebral Trauma—Acute Rehabilitative Phase, ND: impaired physical Mobility.)

Change positions at least every 2 hours (supine, side lying) and possibly more often if placed on affected side.

Position in prone position once or twice a day if client can tolerate.

Identifies strengths and deficiencies and may provide information regarding recovery. Assists in choice of interventions because different techniques are used for flaccid and spastic types of paralysis.

Reduces risk of tissue ischemia and injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown and pressure ulcers.

Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe.

Prevents contractures and footdrop and facilitates use when or

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will:

• Demonstrate techniques and behaviors that enable resumption of activities.

• Maintain skin integrity.

Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.

Use arm sling when client is in upright position, as indicated.

Evaluate use of and need for positional aids and splints during spastic paralysis: Place pillow under axilla to abduct arm.

Elevate arm and hand.Place hard hand-rolls in the palm with fingers and thumb

opposed.

Place knee and hip in extended position.

Maintain leg in neutral position with a trochanter roll.Discontinue use of footboard, when appropriate.

Observe affected side for color, edema, or other signs of compromised circulation.

Inspect skin regularly, particularly over bony prominences.

Gently massage any reddened areas and provide aids such as sheepskin pads, as necessary.

Exercise Therapy: Muscle Control

Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises, such as quadriceps or gluteal exercise, squeezing rubber ball, and extension of fingers and legs and feet.

Assist client to develop sitting balance (such as raise head of bed; assist to sit on edge of bed, having client use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance— put flat walking shoes on client, support client’s lower back with hands while positioning own knees outside client’s knees, and assist in using parallel bars and walker.

Get client up in chair as soon as vital signs are stable except following cerebral hemorrhage.

Pad chair seat with foam or water-filled cushion, and assist client to shift weight at frequent intervals.

if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.

During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome.

Flexion contractures occur because flexor muscles are stronger than extensors.Prevents adduction of shoulder and flexion of elbow.Promotes venous return and helps prevent edema formation.Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position.

Maintains functional position.

Prevents external hip rotation.Continued use after change from flaccid to spastic paralysis can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion.

Edematous tissue is more easily traumatized and heals more

slowly.

Pressure points over bony prominences are most at risk for decreased perfusion and ischemia.

Circulatory stimulation and padding help prevent skin breakdown and decubitus ulcer development.

Minimizes muscle atrophy, promotes circulation, and helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive and imprudent stimulation can predispose to recurrence of bleeding.

Aids in retraining neuronal pathways, enhancing proprioception and motor response.

Helps stabilize BP, restoring vasomotor tone, and promotes maintenance of extremities in a functional position and emptying of bladder and kidneys, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleeding and infarction.

Reduces pressure on the coccyx and prevents skin breakdown.

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Set goals with client/significant other (SO) for increasing participation in activities, exercise, and position changes.

Encourage client to assist with movement and exercises using unaffected extremity to support and move weaker side.

Collaborative

Positioning Provide egg-crate mattress, water bed, flotation device, or

specialized bed, such as kinetic, as indicated.

Exercise Therapy: Muscle ControlConsult with physical therapist regarding active, resistive

exercises and client ambulation.

Assist with electrical stimulation—transcutaneous electrical nerve stimulator (TENS) unit, as indicated.

Administer muscle relaxants and antispasmodics as indicated, such as baclofen (Lioresal) and dantrolene (Dantrium).

Promotes sense of expectation of progress and improvement, and provides some sense of control and independence.

May respond as if affected side is no longer part of body and need encouragement and active training to “reincorporate” it as a part of own body.

Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and pressure ulcer formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia.

Individualized program can be developed to meet particular needs and deal with deficits in balance, coordination, and strength.

May assist with muscle strengthening and increase voluntary muscle control, as well as pain control.

May be required to relieve spasticity in affected extremities.References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p244-245

PRIORITY: Number 3Nursing Diagnosis: Impaired verbal [and/or written] CommunicationMay be related to: Impaired cerebral circulation; neuromuscular impairment, loss of facial or oral muscle tone and control; generalized weakness and fatigueCause Analysis: The cortical area that is responsible for integrating the myriad pathways required for the comprehension and formulation of language is called Broca’s area. It is located in a

convolution adjoining the middle cerebral artery. This area is responsible for control of the combinations of muscular movements needed to speak each word. Broca’s area is so close to the left motor area that a disturbance in the motor area often affects the speech area. This is why so many patients who are paralyzed on the right side (due to damage or injury to the left side of the brain) cannot speak, whereas those paralyzed on the left side are less likely to have speech disturbances. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1908)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Impaired articulation; soft speech or does not or cannot speak

Inability to modulate speech, find and name words, identify objects; inability to comprehend written or spoken language, global

Aphasia Inability to produce written

communication, expressive aphasia

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

• Be able Indicate understanding of the communication problems.

Long-term Objective

Within 3 days of providing nursing interventions, the client will:

• Establish method of communication in which needs can be expressed.

• Use resources appropriately.

Independent

Assess type and degree of dysfunction, such as receptive aphasia—client does not seem to understand words, or expressive aphasia—client has trouble speaking or making self understood:

Differentiate aphasia from dysarthria.

Listen for errors in conversation and provide feedback.

Helps determine area and degree of brain involvement and difficulty client has with any or all steps of the communication process. Client may have trouble understanding spoken words (damage to Wernicke’s speech area), speaking words correctly (damage to Broca’s speech areas), or may experience damage to both areas.

Choice of interventions depends on type of impairment. Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or motor components, such as inability to comprehend written or spoken words or to write, make signs, and speak. A dysarthric person can understand, read, and write language, but has difficulty forming or pronouncing words because of weakness and paralysis of oral musculature, resulting in softly spoken speech.

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Ask client to follow simple commands, such as “Shut your eyes,” “Point to the door”; repeat simple words or sentences.

Point to objects and ask client to name them.

Have client produce simple sounds, such as “sh,” “cat.”

Ask client to write name and/or a short sentence. If unable to write, have client read a short sentence.

Post notice at nurses’ station and client’s room about speech impairment. Provide special call bell if necessary.

Provide alternative methods of communication, such as writing or felt board and pictures. Provide visual clues—gestures, pictures, “needs” list, and demonstration.

Anticipate and provide for client’s needs.

Talk directly to client, speaking slowly and distinctly. Use yes/no questions to start, progressing in complexity as client responds.

Speak with normal volume and avoid talking too fast. Give client ample time to respond. Talk without pressing for a response.

Encourage SO and visitors to persist in efforts to communicate with client, such as reading mail and discussing family happenings even if client is unable to respond appropriately.

Discuss familiar topics—job, family, hobbies, and current events.

Respect client’s preinjury capabilities; avoid speaking down to client or making patronizing remarks.

Collaborative

Consult with or refer to speech therapist.

Client may lose ability to monitor verbal output and be unaware that communication is not sensible. Feedback helps client realize why caregivers are not understanding and responding appropriately and provides opportunity to clarify content and meaning.

Tests for receptive aphasia.

Tests for expressive aphasia—client may recognize item but not be able to name it.

Identifies dysarthria because motor components of speech (tongue, lip movement, breath control) can affect articulation and may or may not be accompanied by expressive aphasia.

Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia.

Allays anxiety related to inability to communicate and fear that needs will not be met promptly. Call bell that is activated by minimal pressure is useful when client is unable to use regular call system.

Provides for communication of needs or desires based on individual situation or underlying deficit.

Helpful in decreasing frustration when dependent on others and unable to communicate desires.

Reduces confusion and anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word and idea association.

Client is not necessarily hearing impaired and raising voice may irritate or anger client. Forcing responses can result in frustration and may cause client to resort to “automatic” speech, such as garbled speech and obscenities.

It is important for family members to continue talking to client to reduce client’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family.

Promotes meaningful conversation and provides opportunity to practice skills.

Enables client to feel esteemed because intellectual abilities often remain intact.

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Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits and therapy needs.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p246-247

PRIORITY: Number 4Nursing Diagnosis: Disturbed Sensory Perception May be related to: Altered sensory reception, transmission, integration—neurological trauma or deficit Psychological stress—narrowed perceptual fields caused by anxietyCause Analysis: Perception is the ability to interpret sensation. Stroke can result in visual-perceptual dysfunctions, disturbances in visual- spatial relations, and sensory loss. Sensory Impairment can

result from a lesion anywhere from the brainstem to the cortex. The higher up the brain injury, the more likely discriminative sensory functions, such as recognition of shape, size or weight of objects are impaired, as opposed to primary sensations of touch, temperature or pain. Impairment may result in the patient being unable to feel a particular sensation, or they may have a crude awareness of a sensation but be unable to differentiate intensities or the qualities of the stimulus. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1897)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Disorientation to time, place, person

Change in behavior pattern and usual response to stimuli; exaggerated emotional responses

Poor concentration, altered thought processes, bizarre thinking

Reported or measured change in sensory acuity: hypoparesthesia, altered sense of taste or smell

Inability to tell position of body parts (proprioception)

Inability to recognize or attach meaning to objects (visual agnosia)

Altered communication patterns

Motor incoordination

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

• Acknowledge changes in ability and presence of residual involvement.

• Demonstrate behaviors to compensate for or overcome deficits.

Long-term Objective

Within 3 days of providing nursing interventions, the client will:

• Regain and maintain usual LOC and perceptual functioning.

Independent

Environmental ManagementReview pathology of individual condition.

Observe behavioral responses such as hostility, crying, inappropriate affect, agitation, and hallucination by using Los Ranchos Scale, as appropriate. (Refer to CP: Craniocerebral Trauma—Acute Rehabilitative Phase, ND: disturbed Thought Processes.)

Eliminate extraneous noise and stimuli as necessary.

Speak in calm, quiet voice, using short sentences. Maintain eye contact.

Ascertain and validate client’s perceptions. Reorient client frequently to environment, staff, and procedures.

Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal or vertical planes), and presence of diplopia

Approach client from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye or encourage wearing of prism glasses if indicated.

Peripheral Sensation ManagementAssess sensory awareness, such as differentiation of hot and

cold, dull or sharp, position of body parts, and muscle and joint sense.

Awareness of type and area of involvement aids in assessing for and anticipating specific deficits and planning care.

Individual responses are variable, but commonalities, such as emotional lability, lowered frustration threshold, apathy, and impulsiveness, may complicate care. Eight-level Los Ranchos Scale aids in documenting progress during initial weeks following insult.

Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload.

Client may have limited attention span or problems with comprehension. These measures can help client attend to communication.

Assists client to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality.

Presence of visual disorders can negatively affect client’s ability to perceive environment and relearn motor skills and increases risk of accident and injury.

Provides for recognition of the presence of persons or objects; may help with depth perception problems; and prevents client from being startled. Patching may decrease the sensory confusion of double vision, and prism glasses may enhance vision across midline, decreasing neglect of affected side.

Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance and positioning (proprioception) and appropriateness of movement, which interferes with ambulation, increasing risk of trauma.

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Stimulate sense of touch—give client objects to touch and grasp. Have client practice touching walls or other boundaries.

Protect from temperature extremes; assess environment for hazards. Recommend testing warm water with unaffected hand.

Note inattention to body parts and segments of environment and lack of recognition of familiar objects or persons.

Encourage client to watch feet when appropriate and consciously position body parts. Make client aware of all neglected body parts using sensory stimulation to affected side and exercises that bring affected side across midline, reminding person to dress and or care for affected (“blind”) side.

Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. Helps client orient self spatially and strengthens use of affected side.

Promotes client safety, reducing risk of injury.

Presence of agnosia (loss of comprehension of auditory, visual, or other sensations, although sensory sphere is intact) may lead to unilateral neglect, inability to recognize environmental cues or meaning of commonplace objects, considerable self-care deficits, and disorientation or bizarre behavior.

Use of visual and tactile stimuli assists in reintegration of affected side and allows client to experience forgotten sensations of normal movement patterns.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p247-248

PRIORITY: Number 5Nursing Diagnosis: Self-Care Deficit May be related to: Neuromuscular impairment, decreased strength and endurance, loss of muscle control and coordination, Perceptual or cognitive impairment, Pain, discomfort, DepressionCause Analysis: As many as 72% of patients who have had a stroke have pain in the shoulder (Duncan, Zorowitz, Bates, et al., 2005). That pain may prevent them from learning new skills and affect

their quality of life. Shoulder function is essential in achieving balance and performing transfers and self-care activities. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1906)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Impaired ability to perform ADLs, such as inability to bring food from receptacle to mouth; inability to wash body part(s) or

regulate temperature of water; impaired ability to put on and take off clothing; difficulty completing toileting tasks

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

• Demonstrate techniques and lifestyle changes to meet self-care needs.

Long-term Objective

Within 3 days of providing nursing interventions, the client will:

• Perform self-care activities within level of own ability.

• Identify personal and community resources that can provide assistance as needed.

Independent

Self-Care AssistanceAssess abilities and level of deficit (0 to 4 scale) for performing

ADLs.

Avoid doing things for client that client can do for self, providing assistance as necessary.

Be aware of impulsive behavior or actions suggestive of impaired judgment.

Maintain a supportive, firm attitude. Allow client sufficient time to accomplish tasks.

Provide positive feedback for efforts and accomplishments.

Create plan for visual deficits that are present, such as the following:Place food and utensils on the tray related to client’s

Aids in anticipating and planning for meeting individual needs.

These clients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for client to do as much as possible for self to maintain self-esteem and promote recovery.

May indicate need for additional interventions and supervision to promote client safety.

Clients need empathy and to know caregivers will be consistent in their assistance.

Enhances sense of self-worth, promotes independence, and encourages client to continue endeavors.

Client will be able to see to eat the food.Will be able to see when getting in or out of bed and observe

anyone who comes into the room.

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unaffected sideSituate the bed so that client’s unaffected side is facing the room with the affected side to the wallPosition furniture against wall, out of travel path

Provide self-help devices, such as button or zipper hook, knifefork combinations, long-handled brushes, extensions for picking things up from floor, toilet riser, leg bag for catheter, and shower chair. Assist and encourage good grooming and makeup habits.

Encourage SO to allow client to do as much as possible for self.

Assess client’s ability to communicate the need to void and ability to use urinal or bedpan. Take client to the bathroom at frequent and scheduled intervals for voiding if appropriate.

Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet. Encourage fluid intake and increased activity.

Collaborative

Administer suppositories and stool softeners.

Consult with rehabilitation team, such as physical or occupational therapist.

Provides for safety when client is able to move around the room, reducing risk of tripping and falling over furniture.

Enables client to manage for self, enhancing independence and self-esteem; reduces reliance on others for meeting own needs; and enables client to be more socially active.

Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process. Note: This may be very difficult and frustrating for the SO/caregiver, depending on degree of disability and time required for client to complete activity.

Client may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses.

Assists in development of retraining program (independence) and aids in preventing constipation and impaction (longterm effects).

May be necessary at first to aid in establishing regular bowel function.

Provides assistance in developing a comprehensive therapy program and identifying special equipment needs that can increase client’s participation in self-care.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p248-249

PRIORITY: Number 6Nursing Diagnosis: Ineffective Coping

May be related to: Situational crises, vulnerability, cognitive perceptual changes

Cause Analysis: The patient’s disability affects not only the patient but also the entire family. In many cases, family therapy is helpful in working through issues as they arise. Rejection of the disability causes self-destructive neglect and noncompliance with the therapeutic program, which leads to more frustration and depression. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1945)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Inappropriate use of defense mechanisms

Inability to cope or difficulty asking for help

Change in usual communication patterns

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

• Talk or communicate with SO about situation and changes

Independent

Coping EnhancementAssess extent of altered perception and related degree of

disability. Determine Functional Independence Measure score.

Identify meaning of the loss and dysfunction or change to client.

Determination of individual factors aids in developing plan of care, choice of interventions, and discharge expectations.

Independence is highly valued in American society, but is not as

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Inability to meet basic needs or role expectations

Difficulty problem-solving

that have occurred.• Verbalize awareness of own

coping abilities.

Long-term Objective

Within 3 days of providing nursing interventions, the client will:

• Verbalize acceptance of self in situation.

• Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.

Note ability to understand events and provide realistic appraisal of situation.

Determine outside stressors, including family, work, social, and future nursing and healthcare needs.

Encourage client to express feelings, including hostility or anger, denial, depression, and sense of disconnectedness.

Note whether client refers to affected side as “it” or denies affected side and says it is “dead.”

Acknowledge statement of feelings about betrayal of body; remain matter-of-fact about reality that client can still use unaffected side and learn to control affected side. Use words such as weak, affected, and right-left, that incorporate that side as part of the whole body.

Identify previous methods of dealing with life problems. Determine presence and quality of support systems.

Emphasize and provide positive I-messages for small gains either in recovery of function or independence.

Support behaviors or efforts such as increased interest and participation in rehabilitation activities.

Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, and withdrawal.

Collaborative

Refer for neuropsychological evaluation and counseling, if indicated.

significant in some other cultures. Some clients accept and manage altered function effectively with little adjustment, whereas others have considerable difficulty recognizing and adjusting to deficits. In order to provide meaningful support and appropriate problem-solving, healthcare providers need to understand the meaning of the stroke and limitations to the client.

Helps identify specific needs, provides opportunity to offer information and support and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination.

Demonstrates acceptance of and assists client in recognizing and beginning to deal with these feelings.

Suggests rejection of body part or negative feelings about body image and abilities, indicating need for intervention and emotional support.

Helps client see that the nurse accepts both sides as part of the whole individual. Allows client to feel hopeful and begin to accept current situation.

Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources.

Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense of progress.

Suggests possible adaptation to changes and understanding about own role in future lifestyle.

May indicate onset of depression (common aftereffect of stroke), which may require further evaluation and intervention.

May facilitate adaptation to role changes that are necessary for a sense of feeling and being a productive person. Note: Depression is common in stroke survivors and may be a direct result of the brain damage or an emotional reaction to sudden-onset disability.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p249-250

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PRIORITY: Number 7Nursing Diagnosis: Risk for impaired SwallowingMay be related to: Neuromuscular or perceptual impairmentCause Analysis: Stroke can result in swallowing problems (dysphagia) due to impaired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. (Smeltzer et. al. [2010]. Brunner and

Suddarth’s Medical Surgical Nursing, 12th ed, p.1907)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Paroxysms of coughing Food dribbling out of or

pooling in one side of the mouth

Food retained for long periods in the mouth,

Nasal regurgitation when swallowing liquids

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

• Demonstrate feeding methods appropriate to individual situation, with aspiration prevented.

Long-term Objective

Within 3 dayss of providing nursing interventions, the client will:

• Maintain desired body weight.

Independent

Swallowing TherapyReview individual pathology and ability to swallow, noting

extent of paralysis, clarity of speech, facial and tongue involvement, ability to protect airway and episodes of coughing or choking; presence of adventitious breath sounds and amount and character of oral secretions. Weigh periodically, as indicated.

Have suction equipment available at bedside, especially during early feeding efforts.

Promote effective swallowing using methods such as the following:Schedule activities and medications to provide a minimum of 30 minutes of rest before eating.

Provide pleasant environment free of distractions, such as TV.

Assist client with head control or support, and position based on specific dysfunction.

Place client in upright position during and after feeding, as appropriate.

Provide oral care based on individual need prior to meal.

Season food with herbs, spices, and lemon juice according to client’s preference, within dietary restrictions.

Serve foods at customary temperature and water always chilled.

Nutritional interventions, including choice of feeding route, are determined by these factors.

Timely intervention may limit amount and untoward effect of aspiration.

Promotes optimal muscle function and helps to limit fatigue.

Promotes relaxation and allows client to focus on task of eating and swallowing.

Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. Optimal positioning can facilitate intake and reduce risk of aspiration—head back for decreased posterior propulsion of tongue, head turned to weak side for unilateral pharyngeal paralysis, and lying down on either side for reduced pharyngeal contraction.

Uses gravity to facilitate swallowing and reduces risk of aspiration.

Clients with dry mouth require a moisturizing agent, such as artificial saliva or alcohol-free mouthwash, before and after eating; clients with excess saliva will benefit from use of a drying agent, such as lemon or glycerin swabs, before meal and a moisturizing agent afterward.

Increases salivation, improving bolus formation and swallowing effort.

Lukewarm temperatures are less likely to stimulate salivation,

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Stimulate lips to close or manually open mouth by light pressure on lips or under chin, if needed.

Place food of appropriate consistency in unaffected side of mouth.

Touch parts of the cheek with tongue blade or apply ice to weak tongue.

Feed slowly, allowing 30 to 45 minutes for meals.

Offer solid foods and liquids at different times.

Limit or avoid use of drinking straw for liquids.

Encourage SO to bring favorite foods.

Maintain upright position for 45 to 60 minutes after eating.

Maintain accurate intake and output (I&O); record calorie count.

Encourage participation in exercise or activity program.

Collaborative

Review results of radiographic studies, such as video fluoroscopy.

Administer intravenous (IV) fluids and/or tube feedings.

Coordinate multidisciplinary approach to develop treatment plan that meets individual needs.

so foods and fluids should be served cold or warm as appropriate. Note: Water is the most difficult to swallow.

Aids in sensory retraining and promotes muscular control.

Provides sensory stimulation (including taste), which may increase salivation and trigger swallowing efforts, enhancing intake. Food consistency is determined by individual deficit. For example: Clients with decreased range of tongue motion require thick liquids initially, progressing to thin liquids, whereas clients with delayed pharyngeal swallow will handle thick liquids and thicker foods better. Note: Pureed food is not recommended because client may not be able to recognize what is being eaten. Most milk products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky.

Can improve tongue movement and control necessary for swallowing and inhibits tongue protrusion.

Feeling rushed can increase stress and level of frustration, may increase risk of aspiration, and may result in client’s terminating meal early.

Prevents client from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after client has finished eating solids.

Although use may strengthen facial and swallowing muscles, if client lacks tight lip closure to accommodate straw or if liquid is deposited too far back in mouth, risk of aspiration may be increased.

Provides familiar tastes and preferences. Stimulates feeding efforts and may enhance swallowing and intake.

Helps client manage oral secretions and reduces risk of regurgitation.

If swallowing efforts are not sufficient to meet fluid and nutrition needs, alternative methods of feeding must be pursued.

May increase release of endorphins in the brain, promoting a sense of general well-being and increasing appetite.

Aids in determining phase of swallowing difficulties—oral preparatory, oral, pharyngeal, or esophageal phase.

May be necessary for fluid replacement and nutrition if client is unable to take anything orally.

Inclusion of dietitian and speech and occupational therapists can increase effectiveness of long-term plan and significantly reduce risk of silent aspiration.

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References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p251-252

PRIORITY: Number 8

Nursing Diagnosis: Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to: Lack of exposure, unfamiliarity with information resources, Cognitive limitation, information misinterpretation, lack of recall

Cause Analysis: Clients have a variety of learning needs and their education is a major aspect of nursing practice and an important independent nursing function. This is multifaceted, involving promoting, protecting and maintaining health. (Fundamentals of Nursing by Kozier p384)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Request for information Statement of misconception Inaccurate follow-through of

instructions Development of preventable

complications

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

Participate in learning process. Verbalize understanding of

condition, prognosis, and potential complications.

Verbalize understanding of therapeutic regimen and rationale for actions.

Long-term Objective

Within 3 days of providing nursing interventions, the client will:

Initiate necessary lifestyle changes.

Independent

Teaching: Disease ProcessEvaluate type and degree of sensory-perceptual involvement.

Include SO and family in discussions and teaching.

Discuss specific pathology and individual potentials.

Identify signs and symptoms requiring further follow-up, such as changes or decline in visual, motor, sensory functions; alteration in mentation or behavioral responses; and severe headache.

Review current restrictions or limitations and discuss planned or potential resumption of activities, including sexual relations.

Review and reinforce current therapeutic regimen, including use of medications to control hypertension, hypercholesterolemia, and diabetes, as indicated and use of aspirin or similar-acting drug, such as ticlopidine (Ticlid) and warfarin sodium (Coumadin). Identify ways of continuing program after discharge.

Provide written instructions and schedules for activity, medication, and important facts.

Encourage client to refer to lists, written communications or notes, and memory book.

Discuss plans for meeting self-care needs.

Refer to discharge planner or home care supervisor and visiting nurse.

Deficits affect the choice of teaching methods and content and complexity of instruction.

These individuals will be providing support and care and have great impact on client’s quality of life.

Aids in establishing realistic expectations and promotes understanding of current situation and needs.

Prompt evaluation and intervention reduces risk of complications and further loss of function.

Promotes understanding, provides hope for future, and creates expectation of resumption of more “normal” life.

Recommended activities, limitations, and medication and therapy needs are established on the basis of a coordinated interdisciplinary approach. Follow-through is essential to progression of recovery and prevention of complications. Note: Long-term anticoagulation may be beneficial for clients prone to clot formation; however, these drugs are contraindicated for CVA resulting from hemorrhage.

Provides visual reinforcement and reference source after discharge.

Provides aids to support memory and promotes improvement in cognitive skills.

Varying levels of assistance may be required and need to be planned for based on individual situation.

Home environment may require evaluation and modifications to meet individual needs.

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Identify community resources, such as National Stroke Association, American Heart Association’s Stroke Connection, stroke support clubs, senior services, Meals on Wheels, adult day care or respite program, and visiting nurse.

Suggest client reduce or limit environmental stimuli, especially during cognitive activities.

Recommend client seek assistance in problem-solving process and validate decisions as indicated.

Identify individual risk factors—hypertension, cardiac dysrhythmias, obesity, smoking, heavy alcohol use, atherosclerosis, poor control of diabetes, and use of oral contraceptives— and discuss necessary lifestyle changes.

Review importance of a balanced diet, low in cholesterol and sodium, if indicated. Discuss role of vitamins and other supplements.

Refer to and reinforce importance of follow-up care by rehabilitation team, such as physical, occupational, speech, and vocational therapists.

Enhances coping abilities and promotes home management and adjustment to impairments for both stroke survivors and caregivers. Note: Recent innovations include such programs as Menu-Direct, which provides fully prepared meal programs with nutrition-rich foods. Some entrees have soufflé-like consistency to help trigger swallowing response.

Multiple or concomitant stimuli may aggravate confusion and impair mental abilities.

Some clients, especially those with right CVA, may display impaired judgment and impulsive behavior, compromising ability to make sound decisions.

Promotes general well-being and may reduce risk of recurrence. Note: Obesity in women has been found to have a high correlation with ischemic stroke.

Improves general health and well-being and provides energy for life activities.

Diligent work may eventually overcome or minimize residual deficits.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p252-253

PRIORITY: Number 9

Nursing Diagnosis: Unilateral Neglect

May be related to: Left hemiplegia from CVA of right hemisphere

Cause Analysis: A stoke patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. (Smeltzer et. al. [2010]. Brunner and Suddarth’s Medical Surgical Nursing, 12th edition, p.1896)

Cues Objectives Nursing Interventions Rationale

Objective Cues

Failure to move eyes, head, limbs, trunk in the neglected hemisphere despite being aware of a stimulus in that space

Appears unaware of positioning of neglected limbs

Lack of safety precautions with regard to the neglected side

Failure to eat food from left

Short-term Objective

Within 8 hours of providing nursing interventions, the client will:

Acknowledge presence of impairment.

Identify adaptive or protective measures for the situation.

Long-term Objective

Independent

Unilateral Neglect ManagementReinforce to client the reality of the dysfunction and need to

compensate, avoiding participation in client’s use of denial.

Instruct client and SO/caregiver in treatment strategies focused on training attention on the neglected side:

Approach client from unaffected side.

Encourage client to turn head and eyes to “scan” the environment.

Enhances dealing with reality of situation, thus avoiding scenarios (denial) that can limit progress and attainment of goals.

Promotes involvement of all individuals in addressing problem, which may enhance recovery.

Enhances client’s awareness and promotes interaction.

Helps client compensate for visual field loss, increasing awareness of environment.

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side of plate and dress or groom neglected side

Failure to notice people approaching from neglected side

Within 3 days of providing nursing interventions, the client will:

Be able adapt to Physical Disability

Demonstrate behaviors, lifestyle changes necessary to promote physical safety.

Discuss affected side while touching, manipulating, and stroking affected side; provide items of varied size, weight, and texture for client to hold.

Have client look at and handle affected side, bring across midline during care activities.

Assist client to position affected extremity carefully and to routinely visualize placement or use a mirror to adjust placement.

Instruct SO/caregiver to monitor alignment of limbs and to inspect skin regularly.

Discuss environmental safety concerns and assist in developing plan to correct risk factors.

Reinforce continuation of prescribed rehabilitation activities and neuropsychological therapies, as indicated.

Focuses client’s attention on left side, and limb activation treatment provides tactile stimuli to promote use of affected limb in neglected hemisphere.

Encourages client to accept affected limb or side as part of self even though it does not feel like it belongs.

Promotes safety awareness, reducing risk of injury.

Decreased sensation and positional awareness may result in pressure injuries.

Client may continue to have some ongoing degree of functional impairment, including difficulty with navigating in familiar environments (Barrett & John, 2007).

Maximizes recovery and enhances independence. Note: Research indicates that most clients with neglect show early recovery, particularly within the first month, and marked improvement within 3 months (Barrett & John, 2007).

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p252-253

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ENDARTERCTOMYCarotid endarterectomy is the most widely used surgical procedure to prevent progressing stroke in symptomatic clients with recurrent TIAs or carotid stenosis. The purpose of a carotid endarterectomy is to remove atherosclerotic plaque from the inner lining of the carotid artery. The goal is to open the artery enough to reestablish blood flow and decrease stroke risk.

CAROTID ARTERY ANGIOPLASTYAlthough angioplasty was introduced in the mid-1980s, it was rarely used in the carotid arteries. However, with the development and refinement of vascular stents, carotid artery angioplasty has become more common. A device called a distal protection device (DSP) can make carotid angioplasty safer than endarterectomy. The DSP is placed beyond the stenosis, which catches any debris that breaks off during the angioplasty/ stenting procedure.this interventional radiology procedure is done under moderate sedation and may eventually be performed as an outpatient procedure.

EXTRACRANIAL- INTRACRANIAL BYPASSThe surgeon performs a craniotomy and bypasses the blocked artery by making a graft or a bypass from the first artery to the second artery. This procedure establishes blood flow around the blocked artery and re-establishes blood flow to the involved areas. The two most common techniques are the superficial middle temporal artery-to-middle cerebral artery (STA-MCA) graft and the occipital-to-posterior inferior cerebellar artery (PICA) bypass.

DECOMPRESSIVE CRANIOTOMYOccasionally, a large stroke can lead to significant brain swelling. When this happens and medicines are not successful in relieving the swelling, a surgical intervention may be required to prevent the pressure buildup within the skull from causing further damage to the brain. In this procedure, the doctor may temporarily open a flap of bone overlaying the swelling in order to alleviate the pressure. If the stroke is of the hemorrhagic type (bleeding), the blood clot may also be removed to prevent further brain injury.

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SURGICAL MANAGEMENTS

CARDIAC THROMBOSIS SURGERYA blood clot can form on the valves or in the chambers of the heart. This can also happen with a prosthetic heart or valve. If the blood clot is not reduced with medication, surgery may be performed. Catheter assisted or open surgical procedures may be necessary to remove the clot. A newer technique called thrombus aspiration may also be employed to remove the blood clot in or around the heart. This technique uses a small vacuum to suction the clot during surgery.

ENDOVASCULAR COIL EMBOLIZATIONA procedure (endovascular coil embolization) is to repair a brain aneurysm that is the cause of a hemorrhagic stroke. A small coil is inserted into the aneurysm to block it off and stop or prevent bleeding.

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Objectives:

1. To teach client the importance of taking the medication strictly for prevention of complication and re-occurrence of the disease.

2. To teach clients various ways on how to do exercises for the prevention of the disease and further eliminating their current illness.

3. To educate the client about the healthy diet and lifestyle of the patient.

Materials needed:.Visual aids.

GENERAL HEALTH TEACHINGS SPECIFIC HEALTH TEACHINGS

Exercise

Medication

Diet

Motivate to start an exercise program especially among people who are sedentary can be deficient

Regular exercise such as PASSIVE ROM

Aerobic exercise such as brisk walking as prescribe by physician

Moderate intensity activities like gardening and walking.

Wear shoes with good traction and cushioning and to examine the feet daily and after exercise

Instruct the client in the purpose and action of each medication

Instruct the client how to properly store the medication

Inform the client of possible of drug to food interaction, as appropriate

Provide written meals plan, as appropriate

Observe the client selection of foods appropriate meals

Encourage patient to eat food that is low in cholesterol, low in saturated fat and high fiber

Eat fruit with the skin to increase the fiber intake

Ate fruits and vegetables rich in vitamins and nutrients

Add vegetables to a sandwich, pizza or stir fry to increase intake

Avoid drinking excessive amount of alcoholic drinks and caffeine-containing beverages and tobacco

Ate fruits and vegetables rich in vitamins and nutrients

Eat high in fiber

Eat fruit with the skin to increase the fiber intake

Add vegetables to a sandwich, pizza or stir fry to increase intake

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HEALTH EDUCATION PLAN

MEDICATIONS Instruct patient to have all of prescriptions filled before he go home. Inform that him that it is very important to follow the dosage as prescribed by the doctor. Also instruct not take any other drugs, supplements, vitamins, or herbs without asking the doctor about them first. Educate patient about the medications to be taken at home, which may include the following:

a. Antiplatelet drugs (aspirin or Clopidogrel) help keep your blood from clotting.

b.Beta blockers or ACE inhibitor medicines may help protect your heart.

c. Diuretics (or water pills), ACE inhibitors, Beta-blockers, and other medications will help control blood pressure.

d.Statins or other drugs that lower your cholesterol.

e. If you have diabetes, control your blood sugar at the level your doctor or nurse recommends.

ENVIRONMENT Inform patient that moving around and doing normal tasks may be hard after a stroke. So, instruct him and his significant others to make their home is safe. Teach patient and his family about what you they can do to prevent falls and injury.

TREATMENTS Encourage patient to always seek professional medical advice about any treatment or change in treatment plans.

Educate patient about other medical or surgical managements that could improvement of his condition.

HEALTH KNOWLEDGE OF DISEASE

Provide health education about cerebrovascular accident, its causes, risk factors, manifestations and complications.

Because of possible injury to the brain from the stroke, inform patient that he may notice problems with:

Changes in behavior Doing easy tasks Memory Moving one side of the body Muscle spasms Paying attention Sensation or awareness of one part of the body Swallowing Talking or understanding others Thinking Seeing to one side (hemianopia)

OUTPATIENT REFERRALS

Instruct patient and caregiver to call doctor if patient experiences:

Problems taking drugs for muscle spasms Problems moving your joints (joint contracture) Problems moving around or getting out of your bed or chair Skin sores or redness Pain that is becoming worse

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DISCHARGE PLAN

Recent falls Choking or coughing when eating Signs of a bladder infection (fever, burning when you urinate, or frequent urination)

Tell them to call 911 if the following symptoms develop suddenly or are new:

Numbness or weakness of the face, arm, or leg Blurry or decreased vision Not able to speak or understand Dizziness, loss of balance, or falling Severe headache

If patient will be using a wheelchair, instruct patient to follow-up visits to make sure it fits well are important to prevent skin ulcers. Instruct patient and caregivers to:

Check every day for pressure sores at the heels, ankles, knees, hips, tailbone, and elbows. Change positions in the wheelchair several times per hour during the day to prevent pressure ulcers.

Provide information to the patient and caregivers about other treatments or therapies to improve patient’s quality of life, which may include the following:

Physiotherapy

Speech therapy

DIET Encourage patient to:

AVOID FATS AND CHOLESTEROL

Inform the patient and caregiver that limiting or avoiding foods that are high in trans-fats, saturated fats and cholesterol may help lower cholesterol levels.

If patient wants to eat meat, instruct to choose lean cuts of meat, and to remove all visible fat and skin. Instruct to broil meats and to pour visible fat off pan-fried foods. Do not use partially hydrogenated oils, use low-fat or fat-free dairy products, and limit sugary foods and drinks.

AVOID SODIUM

Inform the patient and the family that blood pressure may be partially controlled by decreasing salt, or sodium, intake. Tell them that sodium intake should be limited to no more than 1,500 g per day. Encourage to reduce sodium intake by omitting salt from their table and cooking. Also, encourage to limit canned goods, and if they’ll use them, instruct to rinse the contents with water before eating

EAT FIBER

Educate about the advantage of eating foods high in fiber. Inform that this helps lower cholesterol and reduce risk of further strokes. Instruct to incorporate at least five fruits and vegetables into his diet each day, and to switch from white bread products to whole grain or whole wheat. Encourage that instead of using breadcrumbs in meatloaf, use oatmeal.

SPIRITUAL CARE Encourage patient to strengthen his faith to God and to pray, trust and ask guidance from Him.

Provide inspirational messages from the bible.

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PROGNOSIS

Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect people physically, mentally, emotionally, or a combination of the three. The results of stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to areas in the brain that have been damaged.

The outlook depends on:

• The type of stroke• How much brain tissue is damaged• What body functions have been affected• How quickly you get treated

Recovery rates vary depending on the part of the brain affected and the extent of the stroke. Function will be restored in about half of patients with moderate to severe paralysis on one side of the body (hemiplegia) and about 10% will have complete neurologic recovery (Beers). Stroke (all types) has an overall mortality rate of 60.2 per 100,000 individuals; higher mortality occurs in older individuals, in brain stem stroke, or hemorrhagic stroke with alterations of consciousness (Jauch). About 10% to 18% of stroke survivors have a second stroke within a year. Control of risk factors such as high blood pressure, atrial fibrillation, atherosclerosis, obesity, and high lipid levels is important to prevent additional strokes. Of the 4 million people who have had a stroke, about 33% experience mild disability, 20% moderate disability, and 16% require placement in an assisted living facility (Jauch). Rehabilitation is a significant factor in stroke outcomes.

In adults who have had an ischemic stroke, problems that remain after 6 months are likely to be permanent, but children continue to improve slowly for many months. Older people fare less well than younger people. For people who already have other serious disorders (such as dementia), recovery is more limited.

The risk for a second stroke is highest during the weeks or months after the first stroke. Then the risk begins to decrease.

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I. BOOKS

Doenges et. al. (2008). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition.

Ignatavicius D, and Workman M. (2006). Medical- Surgical Nursing Critical Thinking for Collaborative Care 5th edition

Learning, Jones and Barlett (2011). Nurse’s Drug Handbook, 10th edition.

Smeltzer et. al. (2010). Brunner and Suddarth’s Medical Surgical Nursing, 12th edition.

Wilson, N. D. (2008) Manual of Laboratory & Diagnostic Tests.

II. INTERNET

Castillo and Reinoso. (1999) Respiratory Dysfunction Associated with Acute Cerebrovascular Events. Retrieved from http://www.medicosecuador.com/revecuatneurol/vol8_n1-2_1999/respiratory_dysfunction%20.htm.

Neff, D. N. (2012) Surgical Procedures for Stroke. Retrieved from http://www.bidmc.org/YourHealth/TherapeuticCenters/Stroke.aspx?ChunkID=20426

Stroke Health Center (2012) Stroke Surgery. Retrieved from http://www.webmd.com/stroke/guide/stroke-surgery.

MD Guidelines (2012) Cerebrovascular Accident. Retrieved from http://www.mdguidelines.com/cerebrovascular-accident/prognosis

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BIBLIOGRAPHY