Cerebro Vascular Accident

1. CVA ASSESSMENT
RESPIRATORY
- loss of cough reflex, laboured irregular
- wheezing, apnea, coughing when eating,
delayed coughing
- pocketing of food
- difficulty clearing secretions
- Risk for aspiration pneumonia
nursing considerations:
- swallowing assessment
- vital signs
- chest assessment
- positioning and suctioning
- oral care
- encourage deep breathing
GU - BLADDER FUNCTION
- affected body parts (Bladder): incontinence
possible
communication difficulties
mobility problems
Nursing intervention:
- assessment for bladder distension by
palpation
- offer bedpan, commode
- regular bathroom schedule
- assistance with mobility
COMMUNICATION
Aphasia / Dysphasia - impairment in the
ability to comprehend words.
a) Receptive- neither sounds of speech nor
its meaning can be understood.
b) expressive- difficulty in speaking and
writing.
Apraxia- cant move ot control the muscles in
your face (lips, throat, soft palate and tongue)
Dysarthia- unable to control muscles on your
face, mouth and throat.
Nursing Consideration:
- wait for the patient to respond
- be patient with them
-provide alternative communication system-
electronic device or picture in communicating
- encourage to practice
- refer to rehab
SENSORY- Perceptual deficits
AFFECTED: RIGHT brain damage will be:
- difficulty in judging positions
- distance and rate movement are often
impulsive and impatient
- LEFT: brain stroke:
- slower in organization and performance
tasks
Nursing considerations:
- verbal directions
INTEGUMENTARY - risk in skin breakdown
due to loss of sensation, decrease circulation
and immobility
- assess for mobility
- skin assessment
- relieve pressure by repositioning q2
- good hygiene
- adaptive/ proper fitting clothes
MUSKULOSCKELETAL
GOAL: obtain optimal functions t prevent joint
contractors and muscular atrophy
nursing considerations:
- internal shoulder rotation
- flexion contracture of hand/ wrist/ elbow
- external rotation of hip
- plantar flexion of foot
- dependant edema
interventions:

2. - trochanter roll at hip
- hand cones
- arm support with slings / lap board
- avoiding pulling patient by arm
- posterior leg splints / footboard or high
topped shoes
- hand splint to avoid spasticity
GI AND NUTRITION
- LOSS od gag reflex
- bowel incontinence
- constipation
- impaired swallowing
- decreased or absent bowel sounds
nursing intervention:
- increase fluid / fibre
- proper diet
- monitor I&O
- stool softener
- swallowing assessment
COPING
Stroke causes dysrhythmias and conduction
d/o and homeostasis
Nursing Intervention:
- closely monitoring the vital signs or BP
- monitor cardiac rhythm
- calculate inout and output and note the
imbalances
-Risk of DVT : wear TED stockings, passive
exercise and increase movement, assess
legs for redness and swelling and pain
COPING
Assessment:
- diet
- body weight
- Sodium intake
- Range of motion
- glucose level
- depression / behaviour
- urinary / bowel incontinence
- vision / learning impairment
nursing consideration:
- exercise
- meeting with dietician, OT, PT
NUEROLOGICAL
GLASGOW COMA SCALE - measures LOC,
mental status, pupillary responses, extremity
movements and strength
CANADIAN NEUROLOGICAL SCALE -
evaluating and monitoring neurological status
- LOC, orientation, speech
NATIONAL INSTITUTES OF HEALTH
STROKE SCALE