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
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…
Adult Nursing Practice: Care of the Patient with Stroke Introduction Education, especially in the field of nursing, involves both the inculcation of nursing theories, as well as the application of these theories into the clinical practice. The weight of these two components of learning vary depending on the views of the nurse, but some authors claim that the practical application of nursing theories is a more important facet of nursing education.
Case Scenario of a Patient with Left Vascular Accident (CVA /Stroke)
I. Formative Assessment Opportunity for Learning
This paper is about the case scenario of a patient with Left Vascular Accident (CVA/Stroke). I have particularly chosen to write this case because cerebrovascular accident or stroke is one of the most common causes of emergency hospitalisation and unexpected death now a days.
cerebral vascular accident (CVA) is pertaining to “a sudden loss of brain function resulting from a disruption of blood supply to a pert of the brain” (Johnson, 2004, p. 235). Basically, this study will focus in analyzing the case of a 52-year old patients who is at risk of suffering from ischaemic stroke.
The study is also intended to show the role of a nurse in care; including assessment, planning, implementation and evaluation and also in the care given to the patient’s family. In this particular case, the method used was Orems Self-care model (2001) which emphasizes on improving the patient’s state of health and making them feel responsible for their own health
Caregivers are required to employ evidence-based techniques in delivering care to people to ensure for their well being. This has necessitated for them to learn the nature of certain conditions that affect human beings. This paper discusses the issues that relate to a patient suffering from Chronic Obstructive Pulmonary Disease (COPD).
This can be achieved through the kind of students' clinical experiences in varied health care agencies such as acute-care hospitals, residential outpatient psychiatric facilities, extended-care facilities, and community-based health agencies which are integral part of a nursing education.
The sociology of nursing requires that nurses pay close attention to their patients needs so that they feel comfortable and relaxed. In this case, the author finds that these nurses are not fulfilling the historic roles that are established for nurses. Their behaviors are adverse and uncaring, making the patient feel uncared for and neglected.
The end-stage of life, when the patient and his/her family members know about the proximity to death, evokes certain feelings and emotions like rage, denial, bargaining, envy, depression and acceptance (Aranda,
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
Simulation is the use of an act in a bid to explain the aspects of another different act by means of representation emulation and imitation. In nursing and other health care professions simulation can be used to perform four major functions which include training/education, assessing to trainees.
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