Medical Surgical Nursing

 Disturbed sensory perception related to altered sensory reception, transmission,

and/or integration

 Impaired swallowing

 Total urinary incontinence related to flaccid bladder, detrusor instability,

confusion, or difficulty in communicating

 Disturbed thought processes related to brain damage, confusion, or inability to

follow instructions

 Impaired verbal communication related to brain damage

 Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased

mobility

 Interrupted family processes related to catastrophic illness and caregiving burdens

 Sexual dysfunction related to neurologic deficits or fear of failure

Collaborative Problems/Potential Complications
Potential complications include:

 Decreased cerebral blood flow due to increased ICP

 Inadequate oxygen delivery to the brain

 Pneumonia

Planning and Goals
Although rehabilitation begins on the day the patient has the stroke, the process is
intensified during convalescence and requires a coordinated team effort. It is helpful for
the team to know what the patient was like before the stroke: his or her illnesses,
abilities, mental and emotional state, behavioral characteristics, and activities of daily
living (ADLs). It is also helpful for clinicians to be knowledgeable about the relative
importance of predictors of stroke outcome (age, NIHSS score, and level of
consciousness at time of admission) in order to provide stroke survivors and their
families with realistic goals.
The major goals for the patient (and family) may include improved mobility, avoidance
of shoulder pain, achievement of self-care, relief of sensory and perceptual deprivation,
prevention of aspiration, continence of bowel and bladder, improved thought processes,
achieving a form of communication, maintaining skin integrity, restored family
functioning, improved sexual function, and absence of complications.

Nursing Interventions
Nursing care has a significant impact on the patient's recovery. Often, many body
systems are impaired as a result of the stroke, and conscientious care and timely
interventions can prevent debilitating complications. During and after the acute phase,
nursing interventions focus on the whole person. In addition to providing physical care,
the nurse encourages and fosters recovery by listening to the patient and asking
questions to elicit the meaning of the stroke experience.

Improving Mobility and Preventing Joint Deformities
A patient with hemiplegia has unilateral paralysis (paralysis on one side). When control
of the voluntary muscles is lost, the strong flexor muscles exert control over the
extensors. The arm tends to adduct (adductor muscles are stronger than abductors) and
to rotate internally. The elbow and the wrist tend to flex, the affected leg tends to rotate
externally at the hip joint and flex at the knee, and the foot at the ankle joint supinates
and tends toward plantar flexion.