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This Concept Map, created with IHMC CmapTools, has information related to: Stroke, Health Care Need: Acute Intervention of Stroke Key Assessments: 1. Head to toe Physical Assessment 2. Sensory Assessment 3. Pain 4. Safety 5. Coping History: While caring for a 75 year old male you notice the patient experiencing sudden confusion, trouble speaking or understanding. A quick visual assessment shows left sided facial paralysis and flaccid left arm. Rationale: 1. Stroke is the leading cause of death in the United States. 2. Stroke is an important cause of disability, reducing mobility in more than half of stroke survivors over the age of 65 (Stoke fact sheet, n.d.) Related to Key Problem 4: Physical Mobility Nursing Diagnosis: Impaired Physical Mobility Data: * Neuromuscular involvement: weakness, flaccid paralysis; spastic paralysis * Perceptual/cognitive impairment Interventions: * Assess functional ability/extent of impairment initially & regularly * Change Position q 2 hrs. * Position extremities in functional position * Inspect skin regularly * Ger patient up in chair as soon as vital signs are stable Outcomes: * Maintain/increase strength and function of affected/compensatory body part * Maintain optimal position of function * Maintain skin integrity Rationale: * Identifies strengths/deficiencies and may provide information regarding recovery * Reduces risk of tissue ischemia/injury * Prevents contractures/reduces pain * Pressure points over bony prominences are most at risk for decreased perfusion/ischemia (Vera, 2013), Key Problem 5: Ineffective Coping Nursing Diagnosis: Ineffective Coping Data: * Inability to cope/difficulty asking for help * Change in usual communication patterns * Inability to meet basic needs/role expectations * Difficulty problem solving Interventions: * Determine functional independence * Identify meaning of the loss/dysfunction to patient * Determine outside stressors (family, work, social) * Encourage patient to express feelings Outcomes: * Verbalize acceptance of self in situation * Communicate with significant other about situation and changes that have occurred * Verbalize awareness of own coping abilities * Meet psychological needs Rationale * Determination of individual factors aids in developing plan * Independence/ability is highly valued in our society * Identifying outside stressors helps to identify specific needs * Expression of feelings demonstrates acceptance in recognizing and beginning to deal with these feelings (Vera, 2013) Possibly caused by Key Problem 4: Physical Mobility Nursing Diagnosis: Impaired Physical Mobility Data: * Neuromuscular involvement: weakness, flaccid paralysis; spastic paralysis * Perceptual/cognitive impairment Interventions: * Assess functional ability/extent of impairment initially & regularly * Change Position q 2 hrs. * Position extremities in functional position * Inspect skin regularly * Ger patient up in chair as soon as vital signs are stable Outcomes: * Maintain/increase strength and function of affected/compensatory body part * Maintain optimal position of function * Maintain skin integrity Rationale: * Identifies strengths/deficiencies and may provide information regarding recovery * Reduces risk of tissue ischemia/injury * Prevents contractures/reduces pain * Pressure points over bony prominences are most at risk for decreased perfusion/ischemia (Vera, 2013), Health Care Need: Acute Intervention of Stroke Key Assessments: 1. Head to toe Physical Assessment 2. Sensory Assessment 3. Pain 4. Safety 5. Coping History: While caring for a 75 year old male you notice the patient experiencing sudden confusion, trouble speaking or understanding. A quick visual assessment shows left sided facial paralysis and flaccid left arm. Rationale: 1. Stroke is the leading cause of death in the United States. 2. Stroke is an important cause of disability, reducing mobility in more than half of stroke survivors over the age of 65 (Stoke fact sheet, n.d.) Related to Key Problem 1: Hemorrhagic or Ischemic event in the brain. Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion: Data: * Altered level of consciousness: memory loss * Changes in motor/sensory responses * Sensory, language, intellectual & emotional deficits * Altered vital signs Interventions: * Assess visual fields(blurred vision/pupil size), * Neurological status, * Vital signs (Compare BP in both arms, heart rate/rhythm, resp. & basic labs) * Establish last known well time * Provision of supplemental oxygen * Check blood glucose level * Prepare patient for brain imaging - transport to imaging without delay * Evaluate patient for seizure activity * Preventative measures to prevent aspiration - NPO, positioning Outcomes: * Maintain usual/improved LOC, cognition, & motor/sensory function * Demonstrate stable vital signs & absence of signs of increased ICP * Display no further deterioration/recurrence of deficits Rationale: * Pupil reactions are useful in determining whether brainstem is affected * Assessing trends in level neurological status is useful in determining location, extent & progression of central nervous system damage. * Fluctuations in cardiac status may occur and can be diagnostic of location of vascular damage. * Last known well time important since rtPA is ideally administered within 3 hours of symptom onset * Administer supplemental oxygen to patients with hypoxemia * Blood glucose level since hypoglycemia mimics some stroke symptoms * Computed tomography & magnetic resonance imaging is essential in determining whether the stroke is an ischemic infarction or hemorrhage Ischemic stroke accounts for 85% of all strokes. rtPA is treatment of choice for ischemic and surgery is only option for hemorrhagic * Seizures are a possible complication of strokes and can be life-threatening * Pneumonia is a serious complication following ischemic stroke and accounts for approximately 15%-25% of deaths associated with strokes (Summers et al., 2009 & Vera, 2013), Health Care Need: Acute Intervention of Stroke Key Assessments: 1. Head to toe Physical Assessment 2. Sensory Assessment 3. Pain 4. Safety 5. Coping History: While caring for a 75 year old male you notice the patient experiencing sudden confusion, trouble speaking or understanding. A quick visual assessment shows left sided facial paralysis and flaccid left arm. Rationale: 1. Stroke is the leading cause of death in the United States. 2. Stroke is an important cause of disability, reducing mobility in more than half of stroke survivors over the age of 65 (Stoke fact sheet, n.d.) Related to Key Problem 2: Risk for falls Nursing Diagnosis: High risks for falls related to complications following a stroke Data: * Falls are a common cause of injury in stroke patients with hip fractures the most prevalent * Most fractures occur on the paretic side Interventions: * Implement fall-prevention protocol * Educate patient and family members about risks and fall precautions * If available, use bed alarm system * Place call buttons and patient's belongings within reach * Schedule voiding times. Outcomes: * Patient will not fall Rationale: * Hip fractures in the first 7 days after stroke are associated with a poor prognosis. * Education of patient and family will help identify/eliminate fall risks * Placing equipment/belonging within reach avoids the possibility of over-reaching and causing fall * Scheduling voiding times prevents falls that occur when a patient tries to go to the bathroom (Summers et al., 2009), Key Problem 4: Physical Mobility Nursing Diagnosis: Impaired Physical Mobility Data: * Neuromuscular involvement: weakness, flaccid paralysis; spastic paralysis * Perceptual/cognitive impairment Interventions: * Assess functional ability/extent of impairment initially & regularly * Change Position q 2 hrs. * Position extremities in functional position * Inspect skin regularly * Ger patient up in chair as soon as vital signs are stable Outcomes: * Maintain/increase strength and function of affected/compensatory body part * Maintain optimal position of function * Maintain skin integrity Rationale: * Identifies strengths/deficiencies and may provide information regarding recovery * Reduces risk of tissue ischemia/injury * Prevents contractures/reduces pain * Pressure points over bony prominences are most at risk for decreased perfusion/ischemia (Vera, 2013) Caused by Key Problem 1: Hemorrhagic or Ischemic event in the brain. Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion: Data: * Altered level of consciousness: memory loss * Changes in motor/sensory responses * Sensory, language, intellectual & emotional deficits * Altered vital signs Interventions: * Assess visual fields(blurred vision/pupil size), * Neurological status, * Vital signs (Compare BP in both arms, heart rate/rhythm, resp. & basic labs) * Establish last known well time * Provision of supplemental oxygen * Check blood glucose level * Prepare patient for brain imaging - transport to imaging without delay * Evaluate patient for seizure activity * Preventative measures to prevent aspiration - NPO, positioning Outcomes: * Maintain usual/improved LOC, cognition, & motor/sensory function * Demonstrate stable vital signs & absence of signs of increased ICP * Display no further deterioration/recurrence of deficits Rationale: * Pupil reactions are useful in determining whether brainstem is affected * Assessing trends in level neurological status is useful in determining location, extent & progression of central nervous system damage. * Fluctuations in cardiac status may occur and can be diagnostic of location of vascular damage. * Last known well time important since rtPA is ideally administered within 3 hours of symptom onset * Administer supplemental oxygen to patients with hypoxemia * Blood glucose level since hypoglycemia mimics some stroke symptoms * Computed tomography & magnetic resonance imaging is essential in determining whether the stroke is an ischemic infarction or hemorrhage Ischemic stroke accounts for 85% of all strokes. rtPA is treatment of choice for ischemic and surgery is only option for hemorrhagic * Seizures are a possible complication of strokes and can be life-threatening * Pneumonia is a serious complication following ischemic stroke and accounts for approximately 15%-25% of deaths associated with strokes (Summers et al., 2009 & Vera, 2013), Health Care Need: Acute Intervention of Stroke Key Assessments: 1. Head to toe Physical Assessment 2. Sensory Assessment 3. Pain 4. Safety 5. Coping History: While caring for a 75 year old male you notice the patient experiencing sudden confusion, trouble speaking or understanding. A quick visual assessment shows left sided facial paralysis and flaccid left arm. Rationale: 1. Stroke is the leading cause of death in the United States. 2. Stroke is an important cause of disability, reducing mobility in more than half of stroke survivors over the age of 65 (Stoke fact sheet, n.d.) Related to Key Problem 5: Ineffective Coping Nursing Diagnosis: Ineffective Coping Data: * Inability to cope/difficulty asking for help * Change in usual communication patterns * Inability to meet basic needs/role expectations * Difficulty problem solving Interventions: * Determine functional independence * Identify meaning of the loss/dysfunction to patient * Determine outside stressors (family, work, social) * Encourage patient to express feelings Outcomes: * Verbalize acceptance of self in situation * Communicate with significant other about situation and changes that have occurred * Verbalize awareness of own coping abilities * Meet psychological needs Rationale * Determination of individual factors aids in developing plan * Independence/ability is highly valued in our society * Identifying outside stressors helps to identify specific needs * Expression of feelings demonstrates acceptance in recognizing and beginning to deal with these feelings (Vera, 2013), Key Problem 2: Risk for falls Nursing Diagnosis: High risks for falls related to complications following a stroke Data: * Falls are a common cause of injury in stroke patients with hip fractures the most prevalent * Most fractures occur on the paretic side Interventions: * Implement fall-prevention protocol * Educate patient and family members about risks and fall precautions * If available, use bed alarm system * Place call buttons and patient's belongings within reach * Schedule voiding times. Outcomes: * Patient will not fall Rationale: * Hip fractures in the first 7 days after stroke are associated with a poor prognosis. * Education of patient and family will help identify/eliminate fall risks * Placing equipment/belonging within reach avoids the possibility of over-reaching and causing fall * Scheduling voiding times prevents falls that occur when a patient tries to go to the bathroom (Summers et al., 2009) Related to Key Problem 4: Physical Mobility Nursing Diagnosis: Impaired Physical Mobility Data: * Neuromuscular involvement: weakness, flaccid paralysis; spastic paralysis * Perceptual/cognitive impairment Interventions: * Assess functional ability/extent of impairment initially & regularly * Change Position q 2 hrs. * Position extremities in functional position * Inspect skin regularly * Ger patient up in chair as soon as vital signs are stable Outcomes: * Maintain/increase strength and function of affected/compensatory body part * Maintain optimal position of function * Maintain skin integrity Rationale: * Identifies strengths/deficiencies and may provide information regarding recovery * Reduces risk of tissue ischemia/injury * Prevents contractures/reduces pain * Pressure points over bony prominences are most at risk for decreased perfusion/ischemia (Vera, 2013), Health Care Need: Acute Intervention of Stroke Key Assessments: 1. Head to toe Physical Assessment 2. Sensory Assessment 3. Pain 4. Safety 5. Coping History: While caring for a 75 year old male you notice the patient experiencing sudden confusion, trouble speaking or understanding. A quick visual assessment shows left sided facial paralysis and flaccid left arm. Rationale: 1. Stroke is the leading cause of death in the United States. 2. Stroke is an important cause of disability, reducing mobility in more than half of stroke survivors over the age of 65 (Stoke fact sheet, n.d.) Related to Key Problem 3: Pain Nursing Diagnosis: Pain related to affects of stroke Data: * Pain after stroke can be mild, moderate or severe * Pain can be acute or chronic * Pain can be localized or affect on entire side of body affected by stroke * Pain is described as aching, burning, sharp, stabbing or itching Interventions: * Instruct patient to avoid things that can cause pain such as hot baths, tight clothing, and pressure on the side of the body affected by stroke * Teach patient how to position or splint weakened or paralyzed extremity * Administer analgesics at prescribed intervals Outcomes: * Patient eliminates triggers of pain * Patient can demonstrate appropriate position of affected extremity to eliminate pain. * Patient reports relief of pain Rationale * Local pain after stroke is felt in the joints and often the result of unusual positioning of a joint due to spasticity, muscle tightness or stiffness. * Central pain is constant, moderate or sever, and worsened by touch, movement, emotions and changes in temperature (Recovery after stroke: Dealing with pain, 2006), Key Problem 3: Pain Nursing Diagnosis: Pain related to affects of stroke Data: * Pain after stroke can be mild, moderate or severe * Pain can be acute or chronic * Pain can be localized or affect on entire side of body affected by stroke * Pain is described as aching, burning, sharp, stabbing or itching Interventions: * Instruct patient to avoid things that can cause pain such as hot baths, tight clothing, and pressure on the side of the body affected by stroke * Teach patient how to position or splint weakened or paralyzed extremity * Administer analgesics at prescribed intervals Outcomes: * Patient eliminates triggers of pain * Patient can demonstrate appropriate position of affected extremity to eliminate pain. * Patient reports relief of pain Rationale * Local pain after stroke is felt in the joints and often the result of unusual positioning of a joint due to spasticity, muscle tightness or stiffness. * Central pain is constant, moderate or sever, and worsened by touch, movement, emotions and changes in temperature (Recovery after stroke: Dealing with pain, 2006) Caused by Key Problem 1: Hemorrhagic or Ischemic event in the brain. Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion: Data: * Altered level of consciousness: memory loss * Changes in motor/sensory responses * Sensory, language, intellectual & emotional deficits * Altered vital signs Interventions: * Assess visual fields(blurred vision/pupil size), * Neurological status, * Vital signs (Compare BP in both arms, heart rate/rhythm, resp. & basic labs) * Establish last known well time * Provision of supplemental oxygen * Check blood glucose level * Prepare patient for brain imaging - transport to imaging without delay * Evaluate patient for seizure activity * Preventative measures to prevent aspiration - NPO, positioning Outcomes: * Maintain usual/improved LOC, cognition, & motor/sensory function * Demonstrate stable vital signs & absence of signs of increased ICP * Display no further deterioration/recurrence of deficits Rationale: * Pupil reactions are useful in determining whether brainstem is affected * Assessing trends in level neurological status is useful in determining location, extent & progression of central nervous system damage. * Fluctuations in cardiac status may occur and can be diagnostic of location of vascular damage. * Last known well time important since rtPA is ideally administered within 3 hours of symptom onset * Administer supplemental oxygen to patients with hypoxemia * Blood glucose level since hypoglycemia mimics some stroke symptoms * Computed tomography & magnetic resonance imaging is essential in determining whether the stroke is an ischemic infarction or hemorrhage Ischemic stroke accounts for 85% of all strokes. rtPA is treatment of choice for ischemic and surgery is only option for hemorrhagic * Seizures are a possible complication of strokes and can be life-threatening * Pneumonia is a serious complication following ischemic stroke and accounts for approximately 15%-25% of deaths associated with strokes (Summers et al., 2009 & Vera, 2013)