Running head: NURSING ASSESSMENT Nursing Assessment and Care of a Patient following a CVA Focus: Acute neurological deficits (name) (school) (date) Nursing Assessment and Care of a Patient following a CVA Focus: Acute neurological deficits Introduction John Jacobson was admitted to the emergency department for right side hemiparesis, homonymous hemianopsia and expressive aphasia…
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He has not passed urine since admission. He exhibits some paresis, and is leaking saliva at the right side of his mouth. Two possible nursing diagnosis related to this patient’s condition include: Risk for aspiration related to impaired swallowing secondary to cerebrovascular accident; Risk for falls related to bodily weakness, secondary to CVA. This paper shall discuss the patient’s assessment data and interventions which can be implemented for the patient. Body Assessment 1: Risk for aspiration related to impaired swallowing secondary to cerebrovascular accident. This nursing diagnosis relates to this patient’s assessment data because the patient’s swallowing reflex is compromised and he is also unable to control his saliva flow into his tracheobronchial passages. As a result, his saliva getting into his bronchial tubes and on to his lungs is a significant possibility. Two priority nursing interventions to address the problem includes: clear secretions from the mouth or throat with a tissue of gentle suction; and maintain side-lying position. Clear secretions from the mouth or throat with a tissue of gentle suction This intervention would involve the regular checking of the patient’s mouth for saliva build-up, clearing such build-up with a tissue or via gentle suction. Preventing saliva build-up in the mouth prevents the saliva from flowing down the throat and into the bronchial tubes and lungs, thereby preventing aspiration (Carpenito-Moyet, 2008). Moreover, cleaning of the oral cavity would also help prevent the build-up of bacteria. Since the patient manifests right-sided hemiparesis, there is a need to assist the patient in controlling the saliva flow, and prevent such from flowing unconsciously down his throat. Cleaning and suctioning the mouth is suitable because it can easily reduce saliva flow and it can be managed well as an independent nursing intervention by the nurse (Carpenito-Moyet, 2008). Cleaning and suctioning the patient’s mouth would also prevent bacteria build-up and prevent any additional health issues, like aspiration pneumonia, which may arise from the patient’s current condition. Suctioning may however also promote dryness in the patient’s mouth, therefore, the suctioning must not be excessive. Suctioning may also cause oral and throat irritation. If not properly and carried out under sterile conditions, it may promote bacteria build-up (Carpenito-Moyet, 2008). Suctioning must therefore be carried out gently and with the proper application of sterile techniques. The application of suctioning among patients whose swallowing reflexes have been compromises has been proven an effective practice by various researches. In a paper by Coffman, et.al., (2007) the authors sought to investigate the benefits of using cuffed tracheotomy tubes in order to suction patient’s saliva. The authors were able to establish a significant decrease in aspirate with the use of intermittent suction. In effect, the authors concluded that the use of suctions can reduce the risk of aspiration and therefore reduce the patient’s risk for aspiration. This was also echoed in the study by Yoon and Steele (2007), where the authors highlighted the fact that proper oral care is an effective way of reducing incidents of aspiration pneumonia and bacterial colonization in the mouth. Evaluation criteria to establish efficacy of the intervention is
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Case Scenario of a Patient with Left Vascular Accident (CVA /Stroke)
I. Formative Assessment Opportunity for Learning
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