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Symptom management houses 5 elements:
- 1. Nausea
- 2. Vomiting
- 3. dehydration
- 4. Diarrhea
- 5. Constipation
What are some factors that can cause nausea?
- 2. Odors
- 3. Heavy activity (Roller coasters)
- 4. Food intake
What is nausea?
An upleasent wave like motion in the back of the thoart or same motion in the abdonmen
What kind of sympton can produce or be related to vomiting?
- * GI disease
- * Could be related to medication
- * Could be related to Chemotheraphy
- * Anesthesia etc
Abdominal tightening or discomfort
Are all warning signs of what???
What isthe name of the stuff that content that comes out after vomiting?
Does Emesis vary in colour and content?
Yes Emesis does vary in content and colour.
Whatkind of content is made up of Emesis?
- * Emesis may contain undigested food
- * Emesis may containg blood
- * Fresh blood is bright red
- * Dark blood looks like coffee grounds)
What is the medical name for blood vomit?
Example of a nursing diagnosis:
Remember to state the problem
then state what is is related to
Imbalanced nutrition (less than what the body requires) related to nausea and vomiting
Example of a goal:
Client will report fewer episodes of nausea and during a dietry change and two weeks after being placed on a customer diet with proper amt of nutrition
What are some ways a nurse would monitor N amd vomiting?
- * Abdominal assesment (listening for bowel sounds)
- * Keeping track of ACCO- Amt, Colour, Consistency and Odour
- * Intake and Output of fluid
- * Vital signs (BP)
- * Skin tugor
What is Skin tugor?
- A great loos of fluid from the body
- A form of dehydration
Normal Bowel sounds happen?
heard every 5 to 20 seconds
Hypoactive (not very many) bowel sounds
you can hear 1 to 2 sounds every 2mins
Absent bowel sounds?
- When no sounds are heard in 3 -5mins
- This could mean there is a possible bowel obstruction)
Hyperactive bowel sounds
5-6 sounds heard in less then 30 seconds
Some examples of nursing intervention to help with N&V:
- * Decrease clients activity level
- * ensure there is an empty emesis basin in reach for client
- * Remove triggers for N&V from client area (odours)
- * Offer smal amts of bland food
- * Offer small amts of oral fluids
Dimenhydrinate (Gravol) is an example of an Anitemetics (fights agaianst vomiting)
- * A drug that prevents and treats N&V and dizziness
- * This drug is used for many types of N&V
ONDANSETRON (Zofran) is an example of Anitemetics
* Serotonin receptors agonist blocks CNS that affect vomiting pathways.
* it is used to trear vomiting due to chemotheraphy
- * Inhibits vomiting centre in the brain
- * used for short term vomiting
Reason's why a person maybe dehydrated:
(This could be the LAST word in your nursing diagnosis)
- Dehydration (lossof fluid in the body) is related to:
- * Lack of fluid intake
- * Excessive sweating
- * Frequent vomiting and the ability to keep any liquids down
Different causes of Dehydration are OR could be:
- * Antibiotic indueced
- * Polyuria
- * Excessive fluid loss (like high fever, sweating, hot climate etc)
What is Mobility with regards to dehydration?
Mobilities is the skin ease of raising when pinched or testing for dehydration of the skin
What is skin turgor with regrads to dehydration?
Turgor is the skins ability to return back to normal promptly when the pinch is released.
What does BUN stand for?
Blood Urine Nitrogen
Nursing diagnosis for Dehydration is?
1. State the problem
2. Write what it is related to
Deficit fluid volume
- 1. Fluid lost through vomiting
- 2. Diarrhea
- 3. Inadequate fluid intake
What are some Lab results to verify a client is dehydrated?
- Blood Urea Nitrogen ratio increases >20mg
- sodium increases >150mEq/L
- Serum osmolality increased >300mmol/kg
- Urine Specific gravity increase >1.020
- urine color os dark yellow
- urine amt is 800-1200ml/day
Nursing dehydration diagnosis
Deficit fluid volume related to fluid lost through vomiting, diarrhea and inadequate fluid intake.
What are some nursing interventions that can be done to help restore fluid balance?
- *Offer fluids that contain electrolytes
- *Frequent mouth care
What are things you need to monitor?
- Intake and output quality more often
- clients weight, HR, BP, Temp. skin etc
When should you report urine output to the MD?
When the urine output is less then 30ml/h
What are some client outcomes you would like to see with Dehydration?
- output and intake are at the same levels
- Client reports normal skin turgor within 1day
- Client reports absence of vomiting/diarrhea
- Client reports formed stool in 2-3days
What is Irritable bowel Syndrome? (IBS)
abdominal pain and diarrhea or constipation, often associated with stress, depression, anxiety, or previous intestinal infection.
What is Crohn's?
- Body's immune system begins attacking healthy cells in your GI tract, causing inflammation.
- Classified medically as an autoimmune disorder. (means the body is producing antibodies that work against itself.)
What is Ulcerative Colits
It is a chronic, or long-lasting, disease that causes inflammation and sores, called ulcers, in the inner lining of the large intestine.
Who is more susceptible to having diarrhea?
Children and elderly
What signs do you report to the MD right away regarding Diarrhea?
- Urinary output less than 30ml for 2-3 consecutively
- If Potassium levels drop to less than 3.0mEq/L
Why do you report low levels of potassium?
Low levels of potassium can cause cardiac dysrhythmias which can lead to death.
What is hypovolemic shock?
shock caused by severe blood or fluid loss
What is a Barium enema?
barium sulfate is injected into the rectum and X-rays are taken to search for lesions
what are some medical management of diarrhea?
- Focus on what caused the symptoms
- treating underlying causes
- Certain meds can reduce the severity of diarrhea
Deficient fluids volume related to fluid losses secondary to diarrhea. (secondary to chemo)
What are some nursing intervention?
- Stool characteristics
- Abdominal assessment (sounds/ how frequent)
- Vital signs, HR↑, BP↓, Temp. ↑
- Skin integrity / turgur
What are some nursing interventions for diarrhea?
- Bed rest for acute episodes
- Good skin care with mild soap
- frequent fluids, low bulk bland foods
- commode at side of bed
What does a SITZ bath do?
Increases blood flow to the anal and perinal area and soothing to the external tissues
Goal example for Diarrhea
- Stool is normal in colour, in odour frequency and consistancy
- Client has his/her regular pattern of BM
- Signs and symptoms have or will be been resolved in 1 -2days (short term)
- Clients Perianal area skin remains intact
What is constipation?
Abnormal, infrequency or irregular defecation (less than 3x a week)
Pathophysiology for constipation
- Colon absorbs to much water
- weak colon muscles contraction (meaning as you get older the muscles are getting weaker which means less contraction and as a result the feces doesn't move along the GI tract)
What are some causes for Constipation?
- low exercise
- overuse of laxitives
- medication (opioids, anitdepressions)
- Low fibre
What are some secondary cause of constipation?
- bowel obstruction
- Endocrine disorders (hyperthyroidism)
- Muscle disorders, metabolic etc
What are some Manifestations of constipation
- abdominal distenion
- decreased appetite
- gurgling/rumbling sounds in the abdomen (Borborgymus)
What are sine diagnostic test review due to severe constipation?
- Sigmoidoscopy (Colonscopy)
- Stool specimens
What is Sigmoidoscopy
examination of the sigmoid colon by means of a flexible tube inserted through the anus.
What is a megacolon
an abnormal enlargement of the colon
What is hemorrhoids?
a swollen vein or group of veins in the region of the anus
Nursing diagnosis for constipation is:
- Constipation related to
- *side effects of medication (Opiods antidepressants)
- Pain on defecation
- (For ex. side effect from general surgery rectal surgery)
Goal for constipation look like:
- Restore/maintain a regular pattern of elimination within 2 day
- Ensure lots of fluid intake with a high fiber deit
- Long term: Client learns method to prevent constipation. Like training body to go at a certain time
- * client is able to manage anxiety related to constipation
- complications are avoided
Evaluation examples for constipation:
- Clients pattern of bowel function is re-established within 2 day
- Client responds immediately to the urge to defecate daily by sitting on the toilet
- Client passes soft semi-formed stool consistently without straining
What is the function of the bladder?
The bladder, also known as the urinary bladder, is an expandable muscular sac that stores urine before it is excreted out of the body through the urethra
What is the name of thE muscle that contracts to push urine out of the bladder?
What do the internal and external sphincter muscles do?
- The internal & external sphincter muscles form a ring around the urethra to keep urine in the bladder.
- When you are ready to urinate, these muscles relax to allow urine to flow out of the bladder.
What are some nursing interventions that can be used for urinary condition?
- 1. Voiding diary to asses pattern and type
- 2. Measure intake and output
- 3. Ensure sufficient fluid intake
- 4. Ensure privacy for toileting
More Nursing interventions
- 1. Habit training - timed voiding schedule
- 2. Modify environment and easy clothing
- 3. Introduce pelvic floor exercises (Kegels)
What is Supra-pubic tapping?
Tapping the hand over the pelvic area
When would you use intermittent self catherization to empty bladder?
If this patient has spinibiffida
What is urinary retention?
when the bladder is unable to empty itself
How much can the bladder hold in ml of urine?
Can urinary retention lead to UTI
What five things can cause urinary retention?
- 1. Urethral obstruction (ie. enlarged prostate)
- 2. Surgical trauma
- 3. Motor/sensory alterations (I. MS)
- 4. Diabetes
- 5. Post anesthesia
What are Anticholinergics
- *Drugs that block the action of the neurotransmitter acetylcholine in the brain.*The drugs help to block involuntary movements of the muscles associated with these diseases
What are some signs of urinary Retention?
- 1. absence of urinary output
- 2. Bladder distension
- 3. Diaphoresis (sweating)4. Abdominal discomfort
What is the medical term for sweating?
What two main thins a nurse can do to asses urinary retention?
- 1. Palpate bladder
- 2. Monitor volume and frequency
- 3. Monitor post void residuals (PVR) (left over pee)
What is the most prevalent micro-organism founds in UTI's
What does the Parasympathetic system do?
it promotes bladder emptying
What does the Sympathic system do in the urinary system?
Promotes bladder filling
What are some symptons of INCONTINENCE?
- Weakened Pelvic muscle
- Neurogical diesease
- Imparied imobility
- Side effects from some medications
What 6 types of incontinence are there?
- 1. Urge
- 2. Reflex
- 3. Stress
- 4. Over flow
- 5. Functional
- 6. Mixed
Urgency incontinence is?
involuntary elimination of urine is associated with a strong need to void
Reflex incontinence is?
Neurogenic - spinal cord lesion results in no sensory awarness of the need to void an interrupts control by the brain.
Stress incontinence is ?
Weakend perineal muscles permits leakage of urine when intra-abdominal pressure is increased.( ie. laugh sneeze)
Overflow incontinence is?
associated with over distension of bladder and abnormal bladder emptying
Urinary system is intact, but problems such as mobility, cognition, or environment prevent client frm reaching toilet before soiling occurs
What is MIXED incontinence?
this is the presence of more then one typ of incontinence. (ie. stress and urge etc.)
What questions would the nurse ask a client regarding incontinence?
- 1. Inquiry about fluid intake patterns (caffiene/alcohol etc)
- 2. Inquiry about out put patterns. (How many accidents do you have a day? How often do you have the URGE to void?)
- 3. Bowel patterns
- 4. Have you had any previous UTI's?
- 5. Environment? (Location of BR)
- 6. Functional status - ability to get to BR
- 7. Is client cognitive enough? (do they have the ability to ask for help?
What assesments would the nurse do?
- 1. Keep a voiding diary.
- 2. Fluid Intake/Output
- 3. Inspect gentialia area
- 4. If there is odour (possible UTI)
- 5. Palpate bladder
- 7. conduct a bladder examine
What is a Goal for urinary incontinence?
The client will achieve continence (or significantly decrease incontinent episodes) within 2-6months
What is a Goal for urinary incontinence?
The client will maintain optimal dryness at all times effective within 2 weeks (remember this is a liong term goal)
What does SMART stand for?
- Tangible / timely
What are some nursing interventions for incontinence?
- voiding diary
- Ensure privacy
- measure intake output
- Ensure sufficient fluid intake (2-3L per day)
Provide fluid ___ before scheduled voiding times?
Ture or False?
One should you avoid caffeine regarding incontienece
- Caffeine is considered an irritant.
Why should you avoid indwelling catheters?
- having a tube in the bladder is irritating. (not ideal)
- But is better for the skin if the incontinence is really bad
Does using a condom catheter ulter the bladder?
No it does not.
Should we use incontinence briefs and pads as a first resort for a nursing interventions?
no they should be used as last resort because that do not solve the problem
More nursing interventions:
- Provide psychological support (the pt can feel humiliated)
- Clean skin right away
- Refer to continence nurse specialist
What is the nursing diagnosis for Functional incontinence?
Functional incontinence related to impaired mobility (or impaired cognition, or not being able to reach the toilet ontime)
What is the nursing diagnosis for REFELX INCONTINENCE incontinence?
Reflex incontinence related to spinal cord lesions which results in no sensory awareness of need to void
What is the nursing diagnosis for URGE incontinence?
URGE incontinence related to involuntary elimination of urine associated with strong need to void
what are some signs of urinary retention:
- 1. Absence of urinary output
- 2. Sensation of incomplete emptying
- 3. Bladder distention
A nursing assesment for urinary retention could be:
- 1. Palpate bladder
- 2. Monitor volume and frequency of voiding (when was the last time pt voided?)
- 3. Bladder scan
- 4. Monitor Post-void residuals
How do you monitor PVr's?
- 1. Have pt void
- 2. Use bladder scanner or intermitent catherization to measure amt of urine remaining in bladder
- (This is the left over urine)
- Possible Test question!!
what are some nursing intervention for urinary retention:
- 1. Consider cause as to why pt isnt voiding
- 2. Take measure to promote voiding. (ie. running water, maintain adequete fluid intake)
- 3. Intermitten catheterization (MD ordered) This will promote urinary drainage/or releive obstruction
what are some medical treatment to help with Urinary Retention (U.R)
Parasympathomimetic medications (Urecholine) to increase contraction of the detrusor muscle
What is Parasympathomimetic?
drugs that mirror the action of the parasympathetic nervous system of the brain and spinal column
What is Parasympathetic?
- Parasympathetic system (rest and digest system) conserves energy as it slows the heart rate, relaxes sphincter muscles in the gastrointestinal tract.
- * Promotes bladder emptying
What happens if a UTI is left untreated?
It could spread upwards towards the KIDNEYS causing more serious illness. (ie. Pyelonephritis, chronic kidney damage or Urosepsis)
what is Urosepsis?
Urosepsis is a serious secondary infection which occurs when an infection in the urinary tract spreads to the bloodstream.
What is a UTI?
An infection caused by microbes—organisms
Mostly infections involve the lower urinary tract — the bladder and the urethra.
What are some symptoms of LOWER UTI's?
- 1. The bladder and urethra are affected
- 2. Pain/buring while urination
- 3. Fequent nocturia
- 4. Confusion in the older adult
What are some symptons of Upper UTI's
- 1. affects urinary tract above bladder (ie. Ureters, Kidneys)
- 2. P/t feels chills, low back pain, N/V,
- 3. Fever
what is another name for lower urinary tract infection
What is another name for Upper UTI?
pyelonephritis (a kidney infection).
Nursing diagnosis for UTI could be:
- 1. Impaired Urinary Elimination related to:frequent urination, urgency and hesistancy.
- 2. Disturbed Sleep Pattern related to:pain and nocturia
- 3. Acute pain related to: inflammation and infection of the urethra, bladder and other urinary tract structures.
What types odf diagnostic testing is available to UTI's?
- 1. Urinary cultures (C&S) (culture sensitivity)
- 2. Urinary R&M (randome and microscopy)
What is Urinary cultures (C&S) (culture sensitivity)
Test done where they take a sample of the culture from the urine. bag it. grow it in a lab and see which antibiotic will kill the bacteria.
what is urine random and microsocpy?
- Colony count to identify UTI
- count greater than 105 per mi urine is infected
what are some ways we can manage UIT's?
Antibiotics for UITs (ie. Septra, Nitrofurantoin, Ciprofloxacin
Analgesics for pain of UTI
Depending on the UTI you can have:
- 1. A sinal does to get rid og the UTI
- 2. Short course 3 to 4 days
- 3. Regular course 7 - 10 days
What are some things you can teach the P/t?
- 1. Prevention and early recognition of UTI
- 2. Encourage lots of fluids
- 3. Avoid irritants like caffine, tea alcohol & Spices
- 4. void regularly and avoid distending bladder
- 5. Eat cranberries and Vit C.
Should you maintain an open or closed system regarding catheter care (UTI)
Always maintain a closed system
Keep urine bag above the level of the bladder at all times.
TRUE OR FALSE?
- the bag should always be below the level of the bladder to prevent the urine from flowing back into the bladder
Catheters can become colonized by bacteria with 4 weeks of insertion.
TRUE OR FALSE?
- the catheter can become colonzied within 2 weeks
What is PROSTATITIS?
it is inflammation(swollen) of the prostate gland
How does the prostate gland become inflammed?
- microorganisms are carried up the urethra to the prostate
- (Ecoli is most common infection)
Symptons of Prostatitis are:
- 1. Perineal, rectal, or back pain
- 2. Pain with or after ejectualation
- 3. Dysuria, frequency, nocturia, foul urine
- 4. May be asymptomatic (showing no symptoms)
What is Benign Prostatic Hypertrophy? (BPH)
IS AN ENLARGED PROSTATE GLAND
Prostate gland surrounds the urethra, (tube that carries urine from the bladder out of the body). As the prostate gets bigger, it may squeeze or partly block the urethra. (causes problems with urinating.)
Does BPH effect men over 40?
No. Benign Prostate Hypertrophy (BPH) affects men over 50!!
What are some BPH treatments?
- 1. catherterization for urinary retention
- 2. SuperPubic (above pubic bone) catheterization if severe
- 3. Prostatectomy surgery (remove tissue)
- 4. TURP (TransUrethral Resection of Prostate)
What are some meds that can be used to treat BPH?
- 1. Hormonal theraphy
- 2. Alpha-adrenergic receptor blockers to relax smooth muscle of the bladder. (ie. hytrin type of drug that relaxes the smooth muscles of the prostate)
Nursing diagnosis for Prostate enlargement/Urinary retention
Urinary Retention related to urethral obstruction secondary to prostate enlargement or tumor
Short term goal for urinary elimination
the client will improved pattern of urinary elimination over the next 2 weeks. (??)
what are some nursing intervention for UR?
- 1. asses for signs and symptoms of urinary retention
- 2. Catheterize as per doc orders to asses residual urine
- 3. monitor intake output
what is TURP (TransUrethral Resection of Prostate)
•Removal of PROSTATIC_tissue using an instrument inserted via urethra to an area that is blocking urine flow (no incision)
What kind of care will the p/t need after the operation?
- 1. Catheter is used to remove blood or blood clots in the bladder using CBI (continuous bladder irrigation).
- •Catherter can be removed when urine is clear and no clots present
- 2. Monitor labs for changes in hemoglobin
What education needs to be explained to the patient after a TURP
- 1. No strenous activities
- 2. Avoid constipation
- 3.Sexual activity should be avoided (6 wks)
- 4. Frequent urination will continue for a while because of irritation and inflammation caused by the surgery, but they should ease during the first 6 weeks
Exampls of Post-Op Nursing interventions
- •Pain control (pain scale, meds etc.)
- •Vital signs
- •Intake and output
- •Assessing for sepsis and infection
- • incisional care
- •Catheter care
- •Continuous bladder infusion (monitoring, measurement)
- • mobility•Avoid constipation
- •Provide Psychosocial support
What is the reason for Continous bladder irrigation? (CBI)
Used after prostate surgery to prevent obstruction of the urinary tract by blood
How does CBI work?
Solution flows into bladder through one port.
Out of the bladder through another port into the urinary drainage bag
How do you determine urine volume when a CBI is involved?
- monitor volume infused into bladder
- subtract from output from catheter to determine urine volume
With CBI (Continous Bladder Irrigation) remember...
Urine is often pink. If Frank red bleeding occurs it needs to be reported
Large clots need to manually irrigate to remove
What are some complication of CBI?
- •Septic shock especially if patient had a history of UTI
- •Uncontrolled bleeding
- •Electrolyte imbalance
WHAT IS A STROKE?
- A sudden loss of brain function.
- It is caused by the interruption of flow of blood to the brain
What two types of strokes are there?
- 1. Ischemic
- 2. Hemorrhagic
Ischemic stroke is?
Occurs when artery to the brain is blocked as a result blood can not get to the brian
Hemorrhagic stroke is?
is when weakend vessels rupture and bleed out into the brian
Which out of the two strokes results in tissue death?
Which type of stroke is most likely to happen more?
A. Hemorrhagic stroke
B. Ischemic stroke
- B. Ischemic stroke
- 80-85% of strokes are Ischemic
What are the 5 key sugns of stroke?
- 1. Weakness/numbness
- 2. Trouble speaking/understanding
- 3. Vision problems
- 4. headache
- 5. Dizziness
What does TIA stand for?
TRANSIENT ISCHEMIC ATTACKS
What are Transient Ischemic Attacks?
TIA - are temporary disruption of blood flow to the brain. (sometimes called a "mini stroke")
What kind of treatment is out there for TIA's
- Keeping track of it
- Teaching related to risk factors
What are some symptoms a client can experience regarding Hemorrhaic Stroke:
- 1. Sevre headache
- 2. Loss of consciousness
- 3. Neck pain and stiffness
What does ICP stand for?
Intra Cranial Pressure
What is Intra Cranial Pressure?
When there is excessive bleeding in the brain and the pressure builds up and causes damage
What is the primary risk factor for strokes?
Hypertention (high blood pressure)
What is a Secondary prevention treatment for hypertention?
What is Carotid Endarterectomy?
an operation that removes the inner lining of your carotid artery if it has become thickened or damaged. This procedure eliminates plaque from your artery and can restore blood flow.
What type of meds are avail to treat hypertention?
- –Anticoagulant therapy
- –Antiplatelet therapy: aspirin, clopidogrel (Plavix)
- –Statins (decrease lipids and cholesterol)
- –Antihypertensive medications
If taking Statins (decrease lipids and cholesterol) for treatment of hypertention what food should you not eat?
Must not eat grapefruit.
What 3 scales are used for assesments?
- 1. National Institutes of Health Stroke Scale
- 2. Canadian Neurological Scale (CNS)
- 3. Glasgow Coma Scale (GCS)
What does the National Institutes of Health Stroke Scale measure?
Measures neurologic function relates with stroke severity and long-term outcomes in ischemic stroke
What does Canadian Neurological Scale (CNS) measure?
Measures neurological deficit
What does Glasgow Coma Scale (GCS) measure?
- –Measures response to stimuli
- –Often used for hemorrhagic stroke, head injury etc.
- –The lower score, the worse the outcome
what are the 5 motor Deficits?
- 1. Hemiparesis - weakness on one side of body
- 2. Ataxia - lack of co-ordination
- 3. Dysarthria - Difficulty forming words
- 4. Dysphgia - difficulty swallowing
what is Expressive Aphasia? (Broca’s)
Person is unable to form words. (cant talk)
What is Receptive Aphasia? (Wernikes)
Person is unable to understand spoken words
Which of the two types of Aphasia is Broca's and which one is Wernikes
Expressive Aphasia is Broca (control of speech in the brain)
Receptive Aphasia is Wernikes (comprehesion of speech in the brain)
what is Paresthesia:
An abnormal sensation, typically tingling or pricking (“pins and needles”),
caused chiefly by pressure on or damage to peripheral nerves.
Expressive Aphasia (Broca’s):
- •Unable to form words that are understandable
- •Understands others
- •Maybe able to speak in single-word responses
Receptive Aphasia (Wernikes):
- •Unable to understand spoken words
- •Can speak but do not make sense
What are some cognitive issues regarding neurological disorders?
- –Short and long-term memory loss
- –Decreased attention span
- –Inability to concentrate
what are examples of neurology cerebrovascular
diseases of the central and peripheral nervous system. (ie the brain, spinal cord, cranial nerves, peripheral nerves, nerve roots, autonomic nervous system, neuromuscular junction, and muscles.)
What do Neurology cerebrovascular disorders this include?
Epilepsy, Alzheimer disease and other dementias, cerebrovascular diseases including stroke, migraine and other headache disorders, multiple sclerosis, Parkinson's disease, neuroinfections, brain tumours, traumatic disorders of the nervous system such as brain trauma, and neurological disorders as a result of malnutrition.
What are a few Nursing interventions that can help with Neurological CV disorders?
- –Progressive exercise program to improve:
- –muscle strength
- –joint mobility
What are a few Nursing interventions that can help with Neurological CV disorders?
- –Walking techniques- e.g. concentrate on horizon
- –Warm baths and massage to relax muscles
- –Stretching, ROM exercises
What interventions would be appropriate for a client with impaired swallowing?
- –Place food on unaffected side of mouth and watch for pocketing.
- –Have suctioning available
- - Cutfood into small pieces to prevent choking
- - ensure proper food texture is used (ie. minced/pureed, thickened)
What are some nursing interventions for Altered Sensory Perception?
- –ROM to affected limb and assistive devices if needed
- –Teach client to monitor limb during transfers and when positioning self
- –Be aware of temperature of bath water, food etc.
What interventions would be appropriate for a client with sensory impairment (visual)?
- –Approach from side of intact vision
- –Explain location of objects to patient
- –Consistently place objects in same location
- –Place objects within field of intact vision
What interventions would be appropriate for a client with impaired communication?
- –Allow sufficient time to respond
- –Encourage practice of exercises to strengthen facial muscles
- –Short instructions supported with visual cues
- - Speech Language Pathologist
•What interventions would be appropriate for a client with a nursing diagnosis of impaired coping?
- *Teach relaxation exercises
- *Control stressful situations if possible
- *Link to social worker, spiritual care or psychologist as appropriate to situation and need
- *Encourage expression of feelings, concerns, worries
1. •Ineffective airway clearance r/t decreased Level Of Consciousness (LOC), dysarthria (difficulty forming words/speech), dysphagia (swallowing)
1. •Impaired communication r/t dominant hemisphere stroke.
- 2. Impaired swallowing/Risk for aspiration r/t neuromuscular impairment
- (the nerve-muscle (neuromuscular) junction, peripheral nerves in the limbs, and the motor-nerve cells in the spinal cord)
- 1. Anticipatory grieving r/t loss of functional abilities
- 2. •Impaired physical mobility r/t weakness
- 3.•Potential for decreased nutrional intake r/t impaired swallow or decreased LOC
NURSINGINTERVENTIONS for Inadequate Nutrition
- –Keep mealtimes simple and calm…supervise
- –Provide assistance with food, supervise if needed
- –Special utensils (plate stabilizer or non-spill cup)
- –Monitor weight
What are some RISK FACTOR MANAGEMENT to prevent strokes?
–Primary Prevention refers to preventing a FIRST stroke
–Secondary Prevention refers to prevention of stroke following an initial stroke
More risk factors to prevent stroke are>
•May include diet exercise, smoking cessation, weight loss, pharmacological measures etc.
•Key medical concerns: Management of BP, cholesterol, GLUCOSE, depression etc.
RECOVERING FROM STROKE
- •Recovery is influenced by initial degree of impairment
- continues for at least 3-6 months.
- After this point residual (little) progress occurs.
When should rehab and proactive multidisciplinary care begin?