Tia Case Study
NURSING DIAGNOSIS
Ineffective tissue perfusion / Altered cerebral tissue perfusion
Risk for injury: Stroke
Impaired verbal communication r/t ischemic injury
NURSING DIAGNOSIS
Ineffective tissue perfusion / Altered cerebral tissue perfusion
Risk for injury: Stroke
Impaired verbal communication r/t ischemic injury
NURSING INTERVENTIONS
Careful monitoring of neurological status (Glasgow come scale, LOC, pupillary responses, extremity movement and strength, facial symmetry, speech and vital signs). Decrease in LOC may indicate increased ICP.
Tube feedings and IV fluids r/t dysphagia. F/C r/t incontinence, pt is placed on B&B training program.
Preventing contractures, building muscle tone with ROM activities, controlling emotions, increasing field of vision.
Teach pt s/sx of TIA and stroke (FAST) and the need to notify HCP immediately.
NURSING INTERVENTIONS
Careful monitoring of neurological status (Glasgow come scale, LOC, pupillary responses, extremity movement and strength, facial symmetry, speech and vital signs). Decrease in LOC may indicate increased ICP.
Tube feedings and IV fluids r/t dysphagia. F/C r/t incontinence, pt is placed on B&B training program.
Preventing contractures, building muscle tone with ROM activities, controlling emotions, increasing field of vision.
Teach pt s/sx of TIA and stroke (FAST) and the need to notify HCP immediately.
MANAGEMENT
Antiplatelet drugs to reduce risk of future stroke (Aspirin, ticlopidine (Ticlid) and clopidogrel (Plavix))
Thrombolytics such as tissue plasminogen activator (t-PA, alteplase [Activse]) and Heparin, Coumadin
Decadron (dexamethasone) can be given to reduce ICP. Stool softeners, bisacodyl, laxatives.
Bed rest is usually recommended, however some physicians believe early ambulation is best.
Fluids may be restricted for the first few days in an effort to prevent edema of the brain (IV fluids or NG tube)
Surgical interventions to increase blood flow to brain:
Ineffective tissue perfusion / Altered cerebral tissue perfusion
Risk for injury: Stroke
Impaired verbal communication r/t ischemic injury
NURSING DIAGNOSIS
Ineffective tissue perfusion / Altered cerebral tissue perfusion
Risk for injury: Stroke
Impaired verbal communication r/t ischemic injury
NURSING INTERVENTIONS
Careful monitoring of neurological status (Glasgow come scale, LOC, pupillary responses, extremity movement and strength, facial symmetry, speech and vital signs). Decrease in LOC may indicate increased ICP.
Tube feedings and IV fluids r/t dysphagia. F/C r/t incontinence, pt is placed on B&B training program.
Preventing contractures, building muscle tone with ROM activities, controlling emotions, increasing field of vision.
Teach pt s/sx of TIA and stroke (FAST) and the need to notify HCP immediately.
NURSING INTERVENTIONS
Careful monitoring of neurological status (Glasgow come scale, LOC, pupillary responses, extremity movement and strength, facial symmetry, speech and vital signs). Decrease in LOC may indicate increased ICP.
Tube feedings and IV fluids r/t dysphagia. F/C r/t incontinence, pt is placed on B&B training program.
Preventing contractures, building muscle tone with ROM activities, controlling emotions, increasing field of vision.
Teach pt s/sx of TIA and stroke (FAST) and the need to notify HCP immediately.
MANAGEMENT
Antiplatelet drugs to reduce risk of future stroke (Aspirin, ticlopidine (Ticlid) and clopidogrel (Plavix))
Thrombolytics such as tissue plasminogen activator (t-PA, alteplase [Activse]) and Heparin, Coumadin
Decadron (dexamethasone) can be given to reduce ICP. Stool softeners, bisacodyl, laxatives.
Bed rest is usually recommended, however some physicians believe early ambulation is best.
Fluids may be restricted for the first few days in an effort to prevent edema of the brain (IV fluids or NG tube)
Surgical interventions to increase blood flow to brain: