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Nursing Assessment and Care of a Patient Following a CVA
Pages 7 (1757 words)
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.
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. ...
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