Term
| Deficit: Hemiparesis or Hemiplegia (Side of body opposite the cerebral episode) |
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Definition
Nursing Intervention: Position the patient in proper body alightment; use a splint to keep the hand in a functional position.
*provide frequent passive range-of-motion exercises
*re position patient every 2 hours |
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Term
| Deficit: Dysartheria (muscles of speech impaired) |
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Definition
| Nursing Intervention: Provide for an alternative method of communication |
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Term
| Deficit: Dysphagia (muscles of swallowing impaired) |
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Definition
Nursing Intervention: Test palatal and pharngeal reflexes before offering nourishment
*keep NPO until swallow screen completed and oral intake approved by physician
*Elevate and turn the head to the unaffected side
*If able to manage oral intake, place food on the unaffected side of the patient's mouth |
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Term
| Deficit: Homonymous hemianopsia (loss of vision in half of each visual field) |
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Definition
| Nursing Intervention: Approach the patient from the unaffected side; remind the patient to turn the head to compensate for visual deficits |
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Term
| Deficit: Double vision (diplopia) |
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Definition
| Nursing Intervention: Apply an eye patch on the affected eye |
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Term
| Deficit: Decreased visual acuity |
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Definition
| Nursing Intervention: Provide good light and assistance as necessary |
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Term
| Deficit: Absent or diminished response to superficial sensation (touch, pain, pressure, heat, cold) |
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Definition
Nursing Intervention: Increase the amount of touch administrating patient care.
*Protect the involved areas from injury
*Protect the involved areas from burns
*Examine the involved areas for signs of skin irritation and injury
*Provide patient with opportunity to handle various objects of different weight, texture, and size
*If pain is present, assess its location and type as well as the duration of the pain |
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Term
| Deficit: Absent or diminished response to proprioception (knowledge of position of body parts) |
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Definition
| Nursing Intervention: Teach patient to check the position of body parts visually |
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Term
| Deficit: Perceptual deficits (disturbance in perceiving and interpreting self and/or environment). |
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Definition
| Nursing Intervention: Compensate for patient's perceptual-sensory deficits |
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Term
| Deficit: Body scheme disturbance (denial of paralyzed extremities; unilataeral neglect syndrome) |
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Definition
Nursing Intervention: Protect the involved area
*Accept patient's self-perception
*Position patient to face involved area |
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Term
| Deficit: Disorientation (to time, place, and person) |
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Definition
Nursing Intervention: Control amount of changes in patient's schedule
*reorient as necessary
*talk to patient
*provide a calendar, clock, pictures of family, and so forth |
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Term
| Deficit: Apraxia (loss of ability to use object correctly) |
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Definition
| Nursing Intervention:Correct misuse of objects and demonstrate proper use |
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Term
| Deficit: Agnosia (inability to identify the environment by means of senses) |
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Definition
| Nursing Intervention: Correct misconceptions |
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Term
| Deficit: Defects in localizing objects in space estimating their size, and judging distance |
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Definition
| Nursing Intervention: Reduce any stimuli that distracts the patient |
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Term
| Deficit: Impaired memory for recall of spatial location of objects or places |
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Definition
| Nursing Intervention: Place necessary equipment where the patient will see it, rather than telling them the patient "it is in the closet" for example |
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Term
| Deficit: Right-left distortion |
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Definition
| Nursing Intervention: Phrase request carefully, like "lift this leg" (point to leg) |
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Term
| Deficit: Non-fluent aphasia (difficulty in transforming sound into patterns of understandable speech)= can speak using single word responses |
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Definition
| Nursing Intervention: Ask patient to repeat individual sounds of the alphabet as a start to retrain |
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Term
| Deficit: Fluent aphasia (impairment of comprehension of the spoken word) - able to speak, but uses words incorrectly and is unaware of these errors |
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Definition
| Nursing Intervention: Speak clearly and in simple sentences; use gestures as necessary |
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Term
| Deficit: Global aphasia (combination of expressive and receptive aphasia)- unable t o communicate at any level |
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Definition
| Nursing Intervention: Assess for any intact language skills; speak in very simple sentences, ask patient to repeat individual sounds, and use gestures or any other means to communicate |
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Term
| Deficit: Alexia (inability to understand the written word) |
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Definition
| Nursing Intervention: Point to written names of objects and have the patient repeat the name of object |
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Term
| Deficit: Agraphia (inability to express ideas in writing) |
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Definition
| Nursing Intervention: Have patient write words and simple sentences |
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Term
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Definition
| Nursing Intervention: Provide information as necessary |
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Term
| Deficit: Short attention span |
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Definition
| Nursing Intervention: Divide activities into short steps |
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Term
| Deficit: Increased destractiblity |
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Definition
| Nursing Intervention: Control any excessive environmental factors |
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Term
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Definition
| Nursing Intervention: Protect patient from injury especially from falls; institute a fall prevention program |
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Term
| Deficit: Inability to transfer learning from one situation to another |
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Definition
| Nursing Intervention: Repeat and reinforce instructions as necessary |
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Term
| Deficit: Inabilty to calculate, reason, or think abstractly |
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Definition
| Nursing Intervention: Do not create unrealistic expectations in the patient; accept patient as he or she is |
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Term
| Deficit: Emotional lability(exhibits reactions easily or inappropriately) |
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Definition
| Nursing Intervention: Disregard burst of emotions; explain that emotional lability is part of the illness |
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Term
| Deficit: Loss of self-control and social inhibitions (may speak inappropriately, swear, expose self or make sexual advances toward nurse) |
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Definition
| Nursing Intervention: Protect patient as necessary to preserve dignity; recognize involuntary basis of behavior and set limits; anticipate needs |
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Term
| Deficit: Reduced tolerance for stress |
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Definition
| Nursing Intervention: Control environment and maintain routines as much as possible; remove stimuli that upset the patient |
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Term
| Deficit: Fear, hostility, frustration or anger |
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Definition
| Nursing Intervention: Accept the behavior, be supportive |
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Term
| Deficit: Confusion and despair |
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Definition
| Nursing Intervention: Clarify any misconceptions; allow patient to verbalize |
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Term
| Deficit: Withdrawal, isolation |
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Definition
| Nursing Intervention: Provide stimulation and a safe comfortable environment |
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Term
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Definition
| Nursing Intervention: Assess degree of depression; provide a supportive environment; discuss possible pharmacotherapy with physician |
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Term
| Deficit: Bladder Incontience |
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Definition
| Nursing Intervetion: Do NOT suggest insertion of indwelling catheter immediately after the stroke; intermittent cathererization is better than an indwelling foley |
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Term
| Deficit: The unilateral lesion from the stroke results in partial sensation and control of the bladder, so that patient experiences frequency, urgency and incontience |
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Definition
| Nursing Intervention: observe patient to identify characteristics of voiding pattern (e.g. frequency, amount, forcefulness of stream, constant dribbling). |
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Term
| Deficit: If stroke lesion is brainstem, there will be bilateral damage, resulting in an upper motor neuron bladder with loss of all control of micturiation |
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Definition
| Nursing Intervention: Maintain an accurate intake and output record |
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Term
| Deficit: Possibility of establishing normal bladder function is excellent |
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Definition
Nursing Intervention: Try to allow patient to stay catheter free
*offer bedpan or urinal frequently
*take patient to commode frequently
*assess patient's ability to make need for help with voiding known
If a catheter is necessary, remove it as soon as possible and follow a bladder training program |
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Term
Deficit: Altered bowel function in a stroke patient is attributable to:
*Altered LOC
*Dehydration
*Immobilty |
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Definition
Nursing Intervention: Developing a bowel training program:
*provide high-fiber diet to stimulate defecation (prune juice, roughage)
*initiate a suppository and laxative regimen |
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Term
| Deficit: Constipation is most common problem, along with potential impaction |
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Definition
| Nursing Intervention: Institute a bowel program. Enemas are avoided in the presence of increased intracranial pressure |
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