Medical-surgical Nursing Demystified

(Sean Pound) #1

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



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