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Nursing assessment and care of a patient flowing a CVA - Essay Example

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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…
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Nursing assessment and care of a patient flowing a CVA
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Nursing assessment and care of a patient flowing a CVA

agnosis 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.
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.
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 ... Read More
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