CHAPTER 5 Nervous System^251
the brain. Caution is also recommended in patients with head trauma, uncontrolled
hypertension, hemorrhagic retinopathy, gastrointestinal bleeding, recent surgery,
recent MI, or pregnancy.
- Administer TPA (thromoblytic agent) within 3 hours of onset of symptoms,
unless contraindicated. - Administer anticoagulants for patients with ischemic stroke after use of TPA:
- heparin, warfarin, low-molecular weight heparin, aspirin
- Administer antiplatelet medications to decrease platelet adhesiveness; used
to prevent recurrent stroke:- clopidogrel, ticlopidine hydrochloride, dipyridamole
- Administer corticosteroid to decrease swelling:
- dexamethasone (Decadron)
- Physical therapy to help maintain muscle tone or return function.
- Speech therapy to help with speech and swallowing.
- Occupational therapy to help regain function.
- Bed rest to reduce chance of injury.
- Adequate nutrition in appropriate food type for patient.
- Carotid artery endarterectomy to remove plaque from within the carotid artery
if stenosis is present. - Stenting of carotid artery to maintain bloodflow.
- Surgical correction of arteriovenous malformation, aneurysm, intracranial
bleeding.
NURSING DIAGNOSES
- Risk for injury
- Ineffective tissue perfusion
NURSING INTERVENTION
- Monitor vital signs for changes.
- Assess neurological status for signs of deterioration—perform neurological
checks at least every 4 hours—typically use Glasgow Coma Scale or similar
tool to grade response to stimuli (highest score 15):- Eye-opening response spontaneous^4
to sound 3
- Eye-opening response spontaneous^4