A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical emergency that occurs when blood supply to the brain is interrupted. Understanding the nuances of stroke, particularly in the context of nursing care and diagnosis, is paramount for healthcare professionals. This article provides an in-depth exploration of nursing diagnoses related to cerebrovascular disease (CVD), focusing on stroke management and patient care.
Types of Stroke
Strokes are broadly classified into two primary categories: ischemic and hemorrhagic.
Ischemic strokes are the result of a blockage or significant reduction in blood flow to a specific area of the brain. This deprivation of oxygen and essential nutrients leads to rapid brain tissue damage, often within minutes. These blockages are typically caused by fatty deposits, blood clots, or other emboli that travel through the bloodstream to the brain.
Hemorrhagic strokes occur when a blood vessel in the brain ruptures or leaks, causing bleeding into the brain tissue. This accumulation of blood increases intracranial pressure, damaging brain cells. Hemorrhagic strokes can be triggered by various factors, including aneurysms (weakened blood vessel walls), uncontrolled hypertension, head trauma, anticoagulant overuse, cerebral amyloid angiopathy (protein deposits weakening blood vessels), or even as a secondary consequence of an ischemic stroke leading to hemorrhage.
Transient ischemic attacks (TIAs), often referred to as “mini-strokes,” are characterized by temporary disruptions of blood flow to the brain. Symptoms are transient, usually resolving within 24 hours, and most often within an hour, typically without causing permanent damage. However, a history of TIAs is a significant risk factor for future strokes, emphasizing the importance of risk factor modification and preventative strategies.
Image alt text: Diagram illustrating the two main types of stroke: ischemic stroke caused by blockage and hemorrhagic stroke caused by bleeding in the brain.
Nursing Process in Stroke Care
The impact of a stroke on patients is highly variable, ranging from minimal to severe disability. The extent of disability depends on stroke severity, time elapsed before treatment initiation, and any pre-existing health conditions. Initial stroke management usually takes place in intensive care units (ICU) or step-down units, where specialized nurses monitor patients closely. Nurses with NIH Stroke Scale (NIHSS) certification are crucial in these settings due to the rapid and subtle changes in stroke symptoms, demanding critical thinking and timely interventions to prevent neurological deterioration.
Severe strokes can result in profound disability, necessitating complete assistance with basic needs like feeding, bathing, and repositioning. Long-term deficits can be emotionally and physically devastating for both the patient and their families, potentially leading to depression. Nurses play a vital role in providing compassionate care, prioritizing patient safety and dignity while addressing their complex physical and psychosocial needs. This holistic approach is essential in stroke nursing diagnosis and care planning.
Nursing Assessment for Stroke
The nursing assessment is the foundational step in providing effective care. It involves gathering comprehensive physical, psychosocial, emotional, and diagnostic data. This section will detail the subjective and objective data relevant to stroke assessment, crucial for formulating accurate nursing diagnoses for CVD.
Review of Health History
1. Elicit General Stroke Symptoms: Promptly inquire about the presence of any sudden onset symptoms, as these are strong indicators of a possible stroke:
- Hemiparesis or hemiplegia: Weakness or paralysis affecting the face, arm, and leg on one side of the body.
- Sensory deficits: Numbness or tingling sensations (paresthesias) in the extremities.
- Dysphagia: Difficulty swallowing, which can lead to aspiration.
- Visual disturbances: Loss of vision in half of the visual field (hemianopsia) or peripheral vision loss.
- Speech difficulties:
- Expressive aphasia: Inability to articulate words clearly or understandably.
- Receptive aphasia: Difficulty comprehending spoken language.
- Dysarthria: Impaired speech articulation due to muscle weakness.
- Ataxia: Unsteady gait and impaired balance.
- Alterations in balance and coordination.
- Changes in mental status: Confusion, disorientation, or decreased level of consciousness.
2. Determine Symptom Onset: Strokes typically manifest abruptly. It is critical to establish the precise time of symptom onset and the last time the patient was known to be at their normal functional baseline. This information is crucial for determining eligibility for time-sensitive interventions like thrombolytic therapy.
3. Identify Stroke Risk Factors: Several factors increase stroke risk. Assess for the presence of these risk factors:
- Age 55 years and older: Risk increases with age.
- Ethnicity: African American and Hispanic populations have a higher stroke incidence.
- Gender: Males are statistically at a higher risk.
- Prior stroke or TIA: History of stroke or TIA significantly elevates future stroke risk.
4. Review Medical History for Predisposing Conditions: Ischemic strokes, accounting for approximately 87% of all strokes, are often linked to underlying medical conditions that promote blood clot formation or arterial blockage. Inquire about:
- Hypertension: High blood pressure is a major risk factor.
- Obesity: Excess weight increases cardiovascular strain.
- Hypercholesterolemia: High cholesterol contributes to plaque buildup in arteries.
- Diabetes: Diabetes damages blood vessels.
- Obstructive sleep apnea: Sleep apnea is linked to increased stroke risk.
- Heart disease: Conditions like coronary artery disease increase risk.
- Atrial fibrillation: Afib increases clot formation risk.
- COVID-19 infection: Emerging evidence suggests a link between COVID-19 and increased stroke risk.
5. Explore Family History of Stroke: A family history of stroke, especially in immediate relatives before age 65, increases individual stroke risk. Certain genetic conditions, such as CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy), a rare vascular disease, can predispose individuals to stroke.
6. Analyze Medication History: Thoroughly review the patient’s current medications, including dosage, frequency, and adherence.
- Estrogen-containing birth control pills or hormone replacement therapies can increase stroke risk.
- Inconsistent use of blood pressure medications can lead to uncontrolled hypertension and elevated stroke risk.
- Aspirin or other anticoagulants (enoxaparin, heparin, warfarin) may indicate pre-existing clotting disorders or cardiac conditions that increase stroke vulnerability.
7. Inquire about Illicit Substance Use: The use of illegal and highly addictive substances, such as amphetamines, heroin, and cocaine, has been strongly associated with increased stroke risk.
8. Assess Lifestyle Factors: Lifestyle choices significantly influence stroke risk. Evaluate the patient’s habits:
- Diet: High intake of cholesterol, trans fats, and saturated fats is detrimental.
- Physical activity: Insufficient exercise increases cardiovascular risk.
- Alcohol consumption: Excessive alcohol intake is a risk factor.
- Smoking: Smoking damages blood vessels and increases clot risk.
Physical Assessment
1. Utilize F.A.S.T. Recognition: Employ the F.A.S.T. acronym for rapid stroke symptom identification:
- Face: Check for facial drooping or asymmetry.
- Arms: Assess for arm weakness or drift when raised.
- Speech: Evaluate for slurred speech or difficulty speaking.
- Time: Immediately note the time of symptom onset and call for emergency medical assistance.
2. Assess ABCs (Airway, Breathing, Circulation): Perform a primary assessment focusing on airway patency, breathing effectiveness, and circulatory status. Stroke patients are at risk for aspiration and respiratory compromise due to increased intracranial pressure.
3. Conduct a Comprehensive Stroke Assessment: A detailed neurological examination is essential for patients suspected of stroke. The National Institutes of Health Stroke Scale (NIHSS) is the gold standard tool for quantifying stroke severity. It includes assessment of:
- Level of consciousness (LOC)
- Eye gaze
- Visual fields
- Facial palsy
- Motor function in arms
- Motor function in legs
- Limb ataxia
- Sensory function
- Language ability
- Dysarthria
- Inattention/Neglect
4. Monitor Vital Signs: Hypertension is commonly observed in stroke patients. While managing blood pressure is crucial, rapid or excessive blood pressure reduction can be detrimental, especially in the acute phase of ischemic stroke.
Diagnostic Procedures
1. Check Blood Glucose Levels: Immediately perform a fingerstick glucose test to rule out hypoglycemia as a potential cause of neurological changes, as hypoglycemia can mimic stroke symptoms.
2. Prepare for Brain Imaging: Non-contrast head CT is the primary neuroimaging modality for rapid stroke evaluation. It helps differentiate between ischemic and hemorrhagic stroke. Other advanced imaging techniques may include:
- CT angiography (CTA) and CT perfusion scanning (CTP)
- Magnetic resonance imaging (MRI)
- Carotid duplex ultrasound
- Digital subtraction angiography (DSA)
3. Obtain Laboratory Tests: Laboratory investigations assist in identifying underlying stroke etiologies, guiding treatment and prevention strategies. Common tests include:
- Complete blood count (CBC): To assess for conditions like polycythemia or thrombocytopenia.
- Cardiac biomarkers: To evaluate for underlying cerebrovascular disease or coronary artery disease.
- Toxicology screen: To rule out substance intoxication as a cause of stroke-like symptoms.
- Fasting lipid profile: To detect elevated cholesterol levels.
- Coagulation studies: Especially important before administering antiplatelet or anticoagulation medications.
4. Pregnancy Test for Women of Childbearing Age: Urine pregnancy tests are essential for female patients of reproductive age due to contraindications of fibrinolytic therapy in pregnancy.
5. Electrocardiogram (ECG): An ECG is performed to identify potential cardiac arrhythmias, particularly atrial fibrillation (Afib), which can be a source of emboli leading to stroke. Detecting Afib is crucial for initiating anticoagulation therapy to prevent recurrent strokes.
Image alt text: A CT scan image illustrating diagnostic procedures for stroke, emphasizing the importance of brain imaging.
Nursing Interventions for Stroke
Nursing interventions are critical for stroke patient recovery and minimizing long-term disability. This section outlines key nursing interventions in stroke care.
Restore Brain Perfusion
1. Immediate Evaluation and Diagnostic Imaging Preparation: Within one hour of emergency department arrival, patients with stroke symptoms should undergo STAT non-contrast head CT to confirm stroke diagnosis and differentiate between ischemic and hemorrhagic types.
2. Re-establish Blood Flow to the Brain: For confirmed ischemic stroke, initiate alteplase (tissue plasminogen activator or tPA) administration as rapidly as possible. Alteplase is a thrombolytic agent that dissolves blood clots. It is contraindicated in hemorrhagic stroke due to bleeding risk. Administer IV alteplase to eligible patients within a 3-hour window from symptom onset or last known baseline, adhering to AHA/ASA guidelines. In select patients, the window may be extended up to 4.5 hours.
3. Continuous Neurological Monitoring: Frequent neurological assessments are crucial for detecting changes in neurological status and enabling prompt interventions.
- Monitor and document pupil size, equality, and reactivity to light.
- Assess speech, memory, and cognitive function.
- Observe for mood changes or emotional lability.
- Evaluate bilateral muscle strength and coordination.
4. Medication Administration as Prescribed: Prevent secondary complications such as hypertensive crisis, re-bleeding (in hemorrhagic stroke), seizures, and constipation.
- Administer antihypertensive medications to maintain blood pressure within target parameters.
- Initiate seizure prophylaxis, particularly for hemorrhagic strokes or strokes involving the cerebral cortex. Short-term antiseizure medication may be indicated if seizures occur within two weeks post-stroke.
- Prescribe stool softeners or laxatives to prevent straining during bowel movements, as straining can increase intracranial pressure (ICP).
5. Blood Pressure Management: Maintain blood pressure within recommended ranges. For patients receiving IV alteplase, the target blood pressure is typically below 180/105 mm Hg for the first 24 hours. In patients ineligible for fibrinolytic therapy, current guidelines generally recommend permissive hypertension in acute ischemic stroke. Avoid rapid or aggressive blood pressure lowering.
- For ischemic stroke, maintain slightly elevated blood pressure for the initial 2-3 days to counteract vasoconstriction. Subsequently, gradually reduce blood pressure to manage underlying hypertension.
- For hemorrhagic stroke, close blood pressure monitoring is critical, with an immediate goal of systolic blood pressure around 140 mmHg.
6. Prepare for Mechanical Thrombectomy (if indicated): In cases of large vessel occlusion ischemic stroke, mechanical thrombectomy may be performed. This involves using a catheter inserted via the groin to physically remove or dissolve the clot in a major cerebral artery. Ensure informed consent is obtained after the provider discusses risks and benefits with the family.
7. Prepare for Endovascular Procedures: For patients with carotid artery stenosis (plaque buildup), carotid endarterectomy (surgical removal of plaque) or carotid artery stenting (placement of a stent to open the artery) may be performed to improve cerebral blood flow and reduce future stroke risk.
Stroke Recovery and Prevention
1. Stroke Rehabilitation Referral: Facilitate the patient’s recovery and adaptation to stroke-related changes by referring them to comprehensive stroke rehabilitation programs. Referrals may include:
- Speech therapy: To address communication and swallowing difficulties.
- Physical therapy: To improve motor skills, balance, and mobility.
- Occupational therapy: To enhance functional independence in daily living activities.
- Cognitive therapy: To address cognitive deficits like memory and attention.
2. Education on Speech Deficit Management: If aphasia is present, speech therapy is a core component of rehabilitation. Encourage strategies between therapy sessions:
- Consistent implementation of “communication partner training” techniques.
- Speech practice using flashcards, books, computer programs, and visual aids.
- Utilization of communication boards, pen and paper, and assistive technology apps as needed.
3. Medication Education: Educate patients about medications prescribed at discharge, which may include:
- Anticoagulants:
- Oral anticoagulation for atrial fibrillation, such as apixaban, dabigatran, or rivaroxaban.
- Low-dose heparin or enoxaparin for deep vein thrombosis (DVT) prophylaxis.
- Aspirin as a secondary prevention measure.
- Blood pressure medications: To manage hypertension, including diuretics, beta-blockers, calcium channel blockers, and ACE inhibitors.
4. Implement Safety Strategies: Stroke-related weakness and coordination deficits increase fall and injury risk. Implement safety measures:
- Ensure bed rails are raised, bed alarms are activated, and call lights are within reach.
- Provide assistive devices for walking and ADLs as needed.
5. Encourage Support Group Participation: Refer patients and caregivers to local stroke support groups for emotional support, encouragement, and peer interaction with others facing similar challenges.
6. Promote Lifestyle Modifications: Educate patients on lifestyle changes to minimize secondary stroke risk:
- Dietary modifications: Limiting processed foods and saturated fats, adopting a heart-healthy diet.
- Regular exercise: Engaging in daily physical activity as tolerated.
- Smoking cessation: Providing resources and support to quit smoking.
- Limiting alcohol intake.
- Maintaining a healthy weight.
7. Emphasize Treatment Adherence: Stress the importance of adhering to treatment regimens for co-existing conditions like hypertension, diabetes, and hypercholesterolemia to prevent future strokes. Ensure patients understand medication schedules and follow-up appointment requirements.
Nursing Care Plans for Stroke
Once nursing diagnoses for CVD are established, nursing care plans guide the prioritization of assessments and interventions for both short-term and long-term care goals. The following are examples of nursing care plans for common stroke-related nursing diagnoses.
Impaired Verbal Communication
Stroke often leads to communication deficits, including difficulty understanding or expressing speech, and physical limitations affecting speech production.
Nursing Diagnosis: Impaired Verbal Communication
Related Factors:
- Prolonged cerebral occlusion causing neurological damage.
- Dysarthria (weakness of speech muscles).
- Aphasia (impaired language comprehension or production).
As Evidenced By:
- Slurred speech.
- Nonverbal communication or minimal verbal output.
- Difficulty forming words or sentences.
- Difficulty expressing thoughts or ideas.
- Slow responses due to delayed comprehension.
- Extremity weakness or paralysis hindering writing or typing.
Expected Outcomes:
- Patient will establish a functional communication method to express needs and thoughts.
- Patient will actively participate in speech therapy to improve communication skills.
- Patient will effectively utilize communication aids and resources.
Assessment:
1. Determine Type of Aphasia: Global aphasia represents severe impairment in both language production and comprehension. Wernicke’s aphasia may result in fluent but nonsensical speech. Broca’s aphasia involves difficulty with speech production despite understanding language.
2. Observe Communication Methods: Patients may develop unique communication strategies using gestures, signals, or sounds. Family input is valuable in understanding the patient’s individual communication cues.
Interventions:
1. Use Simple and Direct Language: Speak clearly, face the patient, and use short, direct sentences. Avoid abstract concepts. “Yes” or “no” questions may be easiest to comprehend.
2. Implement Alternative Communication Methods: Utilize writing, drawing, or flashcards if effective for the patient. Explore nonverbal communication systems like thumbs up/down, eye blinks, or smiles to establish basic communication.
3. Encourage Speech Therapy Participation: Speech-language therapy is vital for communication recovery. Therapy can help restore language abilities, provide strategies, and introduce assistive communication devices and technologies.
4. Promote Family Involvement: Family participation is essential for both patient and family adaptation to communication changes. Family members should participate in therapy sessions and learn communication-support techniques.
Ineffective Cerebral Tissue Perfusion
Interrupted blood flow to the brain deprives brain tissue of oxygen, potentially leading to irreversible tissue damage.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related Factors:
- Interruption of cerebral blood flow due to stroke.
- Thrombus or embolus formation.
- Arterial occlusion.
- Cerebral edema.
- Hemorrhage.
As Evidenced By:
- Altered mental status, confusion, decreased LOC.
- Blurred vision or visual disturbances.
- Slurred speech or language deficits.
- Extremity weakness or paralysis.
Expected Outcomes:
- Patient will recognize stroke symptoms and seek timely medical attention in the future.
- Patient will demonstrate improved cerebral perfusion evidenced by stable vital signs within prescribed parameters.
- Patient will show improvement in stroke deficits (speech, weakness, swallowing) by discharge.
Assessment:
1. Determine Baseline Neurological Status: Establish the patient’s pre-stroke functional baseline to assess symptom onset and monitor for improvement or deterioration during treatment. The “last known well” time is crucial for thrombolytic eligibility.
2. Perform Neurological Assessments: Regular stroke scale assessments (e.g., NIHSS) monitor LOC, visual changes, facial movement, motor coordination, sensory function, and speech/language deficits.
3. Review Brain Imaging Results (CT/MRI): Neuroimaging confirms or excludes stroke diagnosis and differentiates between ischemic and hemorrhagic stroke, guiding treatment strategies.
Interventions:
1. Manage Blood Pressure: Maintain blood pressure within prescribed parameters to optimize cerebral perfusion. Permissive hypertension may be indicated in ischemic stroke, while lower blood pressure targets are needed in hemorrhagic stroke. Specific blood pressure goals are determined by the provider.
2. Administer Thrombolytic Therapy (if applicable): Administer thrombolytics for ischemic stroke to dissolve clots and restore blood flow. Contraindicated in hemorrhagic stroke. Time-sensitive administration (within 3-4.5 hours of symptom onset) is critical for efficacy.
3. Educate on Stroke Risk Factors: For patients with TIA or minimal residual deficits, emphasize secondary stroke prevention. Educate about modifiable risk factors: hypertension, heart disease, diabetes, smoking, and stress.
4. Teach Stroke Symptom Recognition (FAST): Educate patients and families on F.A.S.T. (Facial drooping, Arm weakness, Speech difficulty, Time to call 911) for rapid stroke recognition and emergency response. “Time is brain” highlights the urgency of stroke treatment.
Risk for Injury
Stroke-related neurological deficits, including spatial-perceptual issues, impaired judgment, weakness, and swallowing difficulties, increase the risk of injury.
Nursing Diagnosis: Risk for Injury
Related Factors:
- Impaired judgment and safety awareness.
- Spatial-perceptual deficits affecting environmental awareness.
- Muscle weakness and impaired motor coordination.
- Poor balance and unsteady gait.
- Impaired time concept and impulsivity.
- Sensory deficits and neglect.
- Dysphagia and aspiration risk.
- Communication impairments.
- Hemiplegia or hemiparesis.
- Short attention span.
Note: Risk diagnoses are not evidenced by existing signs and symptoms; interventions are focused on prevention.
Expected Outcomes:
- Patient will remain free from falls and other injuries.
- Patient will maintain intact skin integrity without pressure ulcers or breakdown.
- Caregivers will create a safe environment and provide support to prevent patient injury.
Assessment:
1. Determine Deficits Related to Brain Area Affected: Right-brain strokes may lead to spatial-perceptual deficits and impulsivity. Left-brain strokes are more likely to cause speech and swallowing impairments.
2. Assess Sensory Awareness: Impaired sensation to pain, temperature, or pressure increases skin breakdown and injury risk.
3. Identify Neglect or Visual Disturbances: Unilateral neglect or hemianopia (visual field loss) increases risk of environmental hazards and self-care deficits.
Interventions:
1. Implement Bed and Chair Alarms: Especially for patients with right-brain strokes and impulsivity, alarms enhance safety and fall prevention.
2. Assist with Eating and Swallowing: For dysphagia, provide appropriate diet textures and thickened liquids. Supervise meals, monitor for aspiration signs (coughing, choking, pocketing food), and ensure proper positioning.
3. Teach Environmental Scanning: For neglect or visual field deficits, teach patients to consciously scan their environment from left to right to improve awareness of surroundings and potential hazards.
4. Frequent Turning and Skin Assessment: For paralyzed or immobile patients, implement a turning schedule (every 2 hours), pressure relief measures for bony prominences, and maintain proper body alignment to prevent skin breakdown.
Self-Care Deficit
Stroke-related hemiparesis or other impairments can significantly impact the ability to perform activities of daily living (ADLs) and self-care.
Nursing Diagnosis: Self-Care Deficit
Related Factors:
- Neurobehavioral manifestations of stroke.
- Muscle weakness and motor impairments.
- Cognitive dysfunction affecting task completion.
- Decreased motivation or apathy.
- Impaired physical mobility.
- Unilateral neglect affecting awareness of one side of the body.
As Evidenced By:
- Inability to independently perform hygiene activities (bathing, grooming).
- Difficulty dressing and undressing.
- Impaired ability to use eating utensils, prepare food, or self-feed.
- Inability to manage toileting independently.
Expected Outcomes:
- Patient will maintain skin integrity and be free from body odor.
- Patient will verbalize successful use of assistive devices for bathing.
- Patient will express dignity and satisfaction with assisted bathing.
- Patient will achieve optimal independence in dressing and ADLs.
- Patient will demonstrate competence in using assistive devices.
- Patient will safely and effectively self-feed.
- Patient will maintain continence and skin integrity in perineal area.
Assessment:
1. Assess Functional Ability and Limitations: Evaluate physical mobility, sensation, cognition, and emotional status to determine the extent of self-care deficits and guide individualized care planning and rehabilitation.
2. Assess Patient Preferences: Respect patient preferences and comfort levels in hygiene and self-care activities to promote dignity and build confidence. Consider cultural or personal preferences in food, hygiene, and self-care routines.
3. Perform Routine Risk Assessments:
- Fall risk assessment (Morse Fall Scale): Identify fall risk factors related to mobility impairments.
- Skin assessment (Braden Scale): Assess pressure ulcer risk related to immobility and sensory deficits.
- Swallowing assessment: Evaluate swallowing function before oral intake to prevent aspiration.
Interventions:
1. Establish a Toileting Schedule: Implement a regular toileting schedule to prevent incontinence and constipation. Administer stool softeners as prescribed and respond promptly to patient requests for toileting assistance.
2. Encourage Independence: Promote patient independence in ADLs to maximize autonomy, self-esteem, and recovery potential.
3. Allow Adequate Meal Times: Patients with swallowing difficulties may require extended time for safe and comfortable meal consumption.
4. Assist with Adaptive Equipment: Introduce and train patients on the use of adaptive equipment (button hooks, zipper pulls, shower benches, electric toothbrushes, specialized utensils, mobility aids) to enhance independence.
5. Consult Physical and Occupational Therapy: Rehabilitation therapies are crucial for relearning impaired skills and developing compensatory strategies for ADLs.
Unilateral Neglect
Unilateral neglect, associated with stroke-induced brain damage, involves impaired awareness of and response to stimuli on one side of the body and environment.
Nursing Diagnosis: Unilateral Neglect
Related Factors:
- Disease process affecting brain function (stroke).
- Brain trauma or damage.
- Ischemia of cerebral tissue.
As Evidenced By:
- Altered safety behaviors on the neglected side (e.g., bumping into objects).
- Failure to move eyes or head towards the neglected side.
- Inability to move limbs on the neglected side.
- Difficulty grooming or attending to the neglected side of the body.
- Unawareness of the position of the neglected limb.
Expected Outcomes:
- Patient will demonstrate techniques to minimize unilateral neglect.
- Patient will appropriately care for both sides of the body and protect the neglected side from harm.
- Patient will achieve the highest possible level of functioning based on individual abilities and goals.
Assessment:
1. Assess for Signs of Unilateral Neglect:
- Neglecting self-care on one side of the body.
- Leaning or bumping into objects on the neglected side.
- Eating food only on one side of the plate.
- Failing to respond to stimuli on the neglected side.
2. Assess Awareness of Neglect: Evaluate the patient’s insight into their neglect and their ability to learn and implement compensatory strategies.
3. Assess Skin on the Neglected Side: Patients with neglect are at higher risk for skin breakdown on the neglected side due to lack of awareness and repositioning.
Interventions:
1. Implement Fall Precautions: Address one-sided weakness and neglect-related safety risks by activating bed alarms and ensuring call light accessibility.
2. Encourage Assistive Device Use: Assistive devices can improve safety and draw attention to the neglected side.
3. Instruct on Neutral Body Positioning: Maintain neutral body alignment and encourage frequent position changes to prevent pain, joint issues, and contractures. Encourage patients to monitor their body position and neglected side.
4. Position Belongings on Unaffected Side: Initially, place personal items and approach the patient from the unaffected side to promote safety and awareness. Gradually encourage attention to the neglected side.
5. Coordinate Rehabilitation Program Referral: Early rehabilitation is crucial. Refer for physical, occupational, and speech therapy as needed to address neglect and maximize functional recovery.
