Nursing management
Cards (11)
- Respiratory system
- risk for aspiration
- could require endotracheal intubation and mechanical ventilation
- Neurological system
- monitor closely to detect changes (cerebral edema peaks in 72 hours)
- sensitive indicator of change is the LOC
- Cardiovascular system
- risk for deep vein thrombosis
- Musculoskeletal system
- risk for joint contractures and muscular atrophy
- risk of fall
- importance of ROM exercises and positioning
- Integumentary system
- susceptible to breakdown
- preventive measure: position on weak side for only 30 minutes due to impaired sensation
- GI system
- most common: constipation
- may need stool softeners or fibre
- Urinary system
- poor bladder control = incontinence
- avoid long term use of indwelling catheters
- Nutrition
- first feeding must be approached carefully
- test for swallowing, chewing, gag reflex and pocketing
- oral hygiene after meal
- Communication
- assess ability to speak and understand
- speak slowly and calmly using simple words or sentences
- gestures may be used to support verbal cues
- give extra time for comprehension and response
- Sensory perceptual alterations
- blindness in same half of each visual field (homonymous hemianopsia)
- could lead to neglect
- Coping
- sensory and intellectual losses
- often go through grief process, may experience long term depression
- changing roles and responsibilities
- very sudden = no time to prepare for illness