N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide Nursing interventions for cerebral vascular accidents: • Monitor neurological status for further decline; changes in level of consciousness • Monitor respiratory status and function; monitor for signs of increased ICP • Monitor fluid intake and output • Give medications per MD order: o TPA (tissue plasminogen activator): Given within 3 hours to increase blood flow. Assess carefully for bleeding, anti-coagulants, surgeries in last two weeks, and head trauma in last three months. This drug can increase bleeding. o Anti-seizure medications: Neurontin and Dilantin o Anti-coagulant medications: Coumadin or IV heparin o Anti-platelet medications: Plavix or Ticlid o Anti-hypertensive medications • Elevate head of bed to promote drainage of secretions and help with increased ICP • If patient complains of paresthesia to a limb, have the patient avoid use of that body part as the dominant part; the limb is more prone to injury with decreased feeling • Provide appropriate nutrition and diet; consult with speech therapy anddietary therapist • Assist with ADLs, feeding, and activities; primary focus of rehabilitation for CVA • Assist with communication: provide writing materials, flash cards, use short questions and explanations, and speak slowly • Assist with passive and active range of motion as tolerated • Refer to physical therapy • Use seizure precautions and maintain patient safety • Prepare patient for surgery if necessary; carotid endarterectomy • Patient and family teaching regarding recovery process, treatment, and needs at home; teach about signs and symptoms of strokes; make sure family knows the importance of anti- coagulant therapy and related lab testing (i.e. PT/PTT with INR) • Patient should report any signs of TIA to physician immediately, as it could be a sign of stroke • Referral to community based support agencies Expected outcomes for cerebral vascular accidents: • Patient remains free from injury • No evidence of skin breakdown • Maintains adequate fluid and nutritional status • Patient maintains ability to communicate needs and feelings • Patient and family can verbalize knowledge of disease management, medications, and safety • Patient maintains compliance with treatment plan, labs, and medications ©2017 Achieve Test Prep Page 111 of 204