Nursing Assessment and Care of a Patient - Literature review Example

?Running head: NURSING ASSESSMENT Nursing Assessment and Care of a Patient following a CVA Focus: Acute neurological deficits (school) 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. He had a CT scan to check for CVA and his chart indicates blockage in the middle cerebral artery. He was given tPA initially at 9mg as a bolus dose, with the rest to be infused over an hour. His BP is beyond the normal range, and he expresses hunger but is on Nil by mouth order. 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 on the auscultation of lung sounds, atleast every four hours to indicate no wheezing or crackling sounds. Lack of such sounds indicates no fluid in the lungs. Maintain side-lying position Maintaining the side-lying position would help facilitate drainage of saliva and prevent such saliva from getting into the patient’s throat (Carpenito-Moyet, 2008). It would also make the easier the suction process and the cleaning of the mouth. Maintaining this side-lying position would ultimately prevent the risk of patient aspiration. In maintaining this position, the patient would have to be assisted in this position, and a change in this position would have to be carried out atleast once every two hours. This intervention is appropriate because it can be carried out by the nurse as an independent nursing intervention (Carpenito-Moyet, 2008). Moreover, this remedy can also be carried out without taking too much of the patient’s time. It can also be carried out by the patient himself, assisted by his family. A negative consequence may be that the patient may forget that he has to remain in this position. Furthermore, he may be too weak to change positions, hence, he may require the assistance of the nurse to maintain such position at most times. A study by Jones, et.al., (2007) was able to highlight the importance of monitoring and recording blood pressure, oxygen saturation, proper positioning, blood glucose and body temperature for stroke patients. Maintaining proper positioning can help prevent complications often attributed to the stroke, including aspiration pneumonia. The side-lying position to manage drooling was also emphasized by Marchiondo (2007) where the authors emphasized that in order to prevent aspiration of patient drool among neurologically compromised patients, placing the patient in a side-lying position can be of significant help. In order to evaluate the efficacy of this intervention, auscultating the patient’s breath sound, reviewing any crackles can be applied by the nurse. Moreover, limited incidents of choking on the patient’s own saliva can also serve as an evaluation tool to assess the efficacy of the intervention. Assessment 2: Risk for falls related to bodily weakness, secondary to CVA The risk of falls relates to the patient’s weakness, especially on his right side. Such weakness also limits his mobility and is likely to cause him to be vulnerable when he attempts to move and when he attempts to change positions in his bed. Due to his CVA, he would likely experience such right-sided weakness for a longer period of time, until the proper remedies for rehabilitation, as well as occupational therapy shall have been implemented. Since the patient’s other faculties are also compromised, his risk for falling is also prevalent. Two priority nursing interventions which can address the problem would be: remove all obstructions to the patient from his bed to the bathroom; teach the patient safe ways to move about. Remove all obstructions to the patient from his bed to the bathroom Obstructions to and from the patient’s bathroom and bed can increase and exacerbate the patient’s risk for falls. Removing such obstructions can help ensure that the patient would not slip, slide, or trip over anything on his way to and from the bathroom. More often than not falls among the elderly are caused by physical obstructions in their passageways, and since the hospitalized patient would likely use the bathroom during the course of his hospitalization, it is important for the nurse to ensure that the path on the way to the bathroom would not be cluttered with unnecessary obstructions, and that such pathway is dry and is free of any slippery spots. It is also advisable to keep the light from the bathroom on, and keep the bathroom door halfway open to allow easy access. In a study by Rubenstein, (2006) the authors were able to emphasize the importance of keeping bathroom and physical access for patients free from any form of obstruction. This study was able to highlight the importance of establishing clear pathways for the elderly and those whose mobility is compromised. Carpets must be taped down, wires must be hidden, and handrails must be readily available in strategic areas for these patients to access (Rubenstein, 2006). These measures help prevent injuries and falls among these patients, helping facilitate their mobility and their overall independent functioning. The rooms of these patients must also be close to the nurses’ station in order to facilitate monitoring and to ensure that the patient can be heard when he would call out for assistance. In any case, these elderly patients must be taught how to use the call button, to seek assistance during difficult tasks which calls for their mobility (Cesari, et.al., 2002). Patient education – mobility It is also important to teach the patient safe and appropriate ways to work around their condition and their limited mobility. It is important to teach these patients how to get up from a lying position to a sitting-up position safely, then to swing their legs to the floor in preparation for standing up. Small shuffling steps can be taught to the patient and assistance must be made available to the patient where possible. These remedy would help promote the patient’s independence despite his immobility. It would also teach him ways on how to safely navigate from one area of his room to another or in carrying out his different activities. By teaching the patient these safe techniques, he would know the importance of the precautions he needs to undertake in relation to his condition. There are positive and negative consequences of this intervention. Positive consequences include the reduced risk of falls for the patient and the maintenance of the patient’s mobility. However, it may also cause negative effects with the patient trying to attempt some of the activities on his own and later placing himself at a greater risk for injuries because of such attempts. In a study by Cumming, et.al., (2008) the authors established that by teaching the patient ways by which he can protect himself from falls, he is taking a more active role in his care. This makes his compliance in his treatment more active, and makes his participation in the activities more engaged. In a paper by Wasson, et.al., (1999), the authors were also able to establish that the patient’s more active participation in their care allowed them to be feel more engaged in their own care. It also allowed their understanding of their condition to motivate the application of improvements in their care. In order to assess the efficacy of this remedy, reduced or no incidents of falls within the patient’s hospital stay is the best evaluation. Moreover, the patient’s application of safe techniques in mobility can also help ensure that this remedy is being effective for the patient. Nevertheless, the patient must be able to easily navigate his way from the bathroom to his bed or around his room without experiencing any injuries or falls. Conclusion The patient has suffered a cerebrovascular accident which has greatly compromised his mobility, functioning, and has caused the appearance of other neurological symptoms. The patient’s nursing diagnosis includes the following: risk for aspiration related to impaired swallowing secondary to cerebrovascular accident and risk for falls related to bodily weakness secondary to CVA. The first diagnosis can be managed by clearing secretions through a tissue of through gentle suctions. The second diagnosis can be managed by removing all obstructions which may cause patient falls and by educating the patient on proper mobility. These interventions can benefit the patient’s health by preventing the exacerbation of his current conditions. His condition is very much serious and most of the remedies to repair his major issue would have to come from doctor’s orders. The role of the nurse now would be to prevent his health problems from actually getting worse. Works Cited Carpenito-Moyet, L. (2008). Nursing diagnosis: application to clinical practice. Philadelphia: Lippincott Williams & Wilkins. Cesari, M., Landi, F., Torre, S., Onder, G., & Lattanzio, F. (2002). Prevalence and Risk Factors for Falls in an Older Community-Dwelling Population. J Gerontol A Biol Sci Med Sci, volume 57 (11): pp. M722-M726. Coffman, H., Rees, C., Sievers, A., & Belafsky, P. (2007). Proximal suction tracheotomy tube reduces aspiration volume. Topics in Geriatric Rehabilitation, volume 23(3), pp. 280-288. Haines, T., Hill, K., Bennell, K. & Osborne, R. (2006). Patient education to prevent falls in subacute care. Clin Rehabil, volume 20(11), pp. 970-979. Jones, S., Leathley, M., McAdam, J., & Watkins, C. (2007). Physiological monitoring in acute stroke: a literature review. Journal of Advanced Nursing, volume 60(6), pp. 577–594 Marchiondo, K. (2007). Transesophageal Imaging and Interventions: Nursing Implications. Critical Care Nurse, volume 27: pp. 25-35. Rubenstein, L. (2006). Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing, volume 35 (suppl 2): pp. ii37-ii41. Wasson, O., Stukel, T., Weiss, J., Hays, R., & Jette, A. (1999). Randomized Trial of the Use of Patient Self-Assessment Data To Improve Community Practices. American College of Physicians. Retrieved 24 September 2011 from http://www.howsyourhealth.com/html/JWasson1.pdf Yoon, M. & Steele, C. (2008). The Oral Care Imperative: The Link Between Oral Hygiene and Aspiration Pneumonia. Otolaryngol Head Neck Surg, volume 138(4), pp. 441-445. Read More