Medical-surgical Nursing Demystified

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