Nursing Process: The Patient Recovering from an Ischemic Stroke
Assessment
- Acute phase
- Ongoing/frequent monitoring of all systems including vital signs and neurologic
assessment— LOC, motor symptoms, speech, eye symptoms - Monitor for potential complications including musculoskeletal problems,
swallowing difficulties, respiratory problems, and signs and symptoms of increased
ICP and meningeal irritation
- Ongoing/frequent monitoring of all systems including vital signs and neurologic
- After the stroke is complete
- Focus on patient function; self-care ability, coping, and teaching needs to facilitate
rehabilitation
- Focus on patient function; self-care ability, coping, and teaching needs to facilitate
Nursing Process: Diagnoses
— Impaired physical mobility
— Acute pain
— Self-care deficits
— Disturbed sensory perception
— Impaired swallowing
— Urinary incontinence
— Disturbed thought processes
— Impaired verbal communication
— Risk for impaired skin integrity
— Interrupted family processes
— Sexual dysfunction
Collaborative Problems/Potential Complications
- Decreased cerebral blood flow
- Inadequate oxygen delivery to brain
- Pneumonia
Nursing Process: Planning
- Major goals may include: