Overview
A transient ischemic attack (TIA), often referred to as a “mini-stroke,” is a fleeting episode of symptoms that mimic a stroke. Although TIAs are brief, typically lasting only a few minutes and not causing permanent brain damage, they are critical warning signs of a potential future stroke. Recognizing and responding to TIAs promptly is crucial in stroke prevention.
In a TIA, the brain’s blood supply is temporarily interrupted, leading to stroke-like symptoms that resolve quickly without lasting effects. Atherosclerosis, characterized by the buildup of fatty deposits containing cholesterol within artery walls, is a primary underlying cause. These cholesterol plaques can either trigger clot formation or restrict blood flow through an artery. Furthermore, a TIA can occur when a blood clot travels from another part of the body to a brain-supplying artery.
Various modifiable and non-modifiable risk factors contribute to the occurrence of TIAs. The main objective of TIA management is to decrease the likelihood of subsequent TIAs or a full stroke. This often involves a combination of medication, preventive surgical interventions, and lifestyle adjustments.
Nursing Assessment
The cornerstone of effective nursing care begins with a thorough nursing assessment. This process involves gathering comprehensive data encompassing physical, psychosocial, emotional, and diagnostic aspects of the patient’s condition. This section will delve into the subjective and objective data collection pertinent to transient ischemic attacks.
Review of Health History
1. Inquire about the patient’s symptoms. Recognizing the warning signs of a TIA is crucial. Key symptoms to ask about include:
- Unilateral weakness, numbness, or paralysis, often affecting the face, arm, or leg on one side of the body.
- Disturbances in balance and coordination, leading to unsteadiness or difficulty walking.
- Slurred speech or difficulty articulating words (dysarthria).
- Swallowing difficulties (dysphagia).
- Visual disturbances such as double vision or sudden vision loss in one or both eyes.
- Dizziness or vertigo, characterized by a spinning sensation.
- Confusion or altered mental state.
2. Obtain a detailed history of the present illness. Carefully explore the specifics of the symptoms, including their onset, duration, and severity. Essential questions during history taking should cover:
- When did the symptoms begin? (Onset)
- How long did the symptoms last? (Duration)
- What time of day did the symptoms occur? (Time of occurrence)
- What specific neurological symptoms did you experience (e.g., weakness, speech difficulty, vision changes)? (Neurological symptoms)
- Were there any other symptoms associated with these neurological changes (e.g., headache, nausea)? (Related symptoms)
- What factors seemed to worsen or improve your symptoms? (Aggravating or alleviating factors)
3. Identify the patient’s risk factors for TIA. Understanding risk factors is vital for preventative care. These factors are broadly categorized into modifiable and non-modifiable risks:
- Personal or family history of conditions predisposing to blood clots (hypercoagulability disorders), stroke, or previous TIAs.
- Age over 55 years.
- Male sex.
- Smoking history.
- Excessive alcohol consumption.
- Drug abuse or substance misuse.
- Obesity or being overweight.
- Sedentary lifestyle with minimal physical activity.
- Unhealthy dietary habits.
4. Review the patient’s past medical history. Certain pre-existing health conditions significantly increase the likelihood of experiencing a TIA. These comorbidities include:
- Cardiovascular diseases, such as coronary artery disease and heart failure.
- Atrial fibrillation, an irregular heart rhythm.
- Obstructive sleep apnea.
- History of prior strokes or TIAs.
- Infections of the central nervous system.
- Peripheral vascular disease.
- Coagulopathies or bleeding disorders.
- Migraine headaches.
- Diabetes mellitus.
- Dyslipidemia or abnormal lipid levels.
- Hypertension or high blood pressure.
- Sickle cell disease.
- Recent Covid-19 infection.
5. Review the patient’s current medications. A thorough medication review is essential. This includes prescribed medications, over-the-counter (OTC) drugs, and supplements. It’s also important to assess for any history of substance misuse or abuse.
6. Interview witnesses or family members. Gather information from witnesses, family members, or emergency medical services (EMS) personnel regarding any sudden changes in the patient’s cognition or motor function. Document findings related to changes in:
- Behavior or personality.
- Speech patterns.
- Gait or walking ability.
- Memory function.
- Movement or coordination.
Physical Assessment
1. Assess TIA risk using validated tools. The ABCD2 score is a widely used risk stratification tool to predict the likelihood of stroke after a TIA. The ABCD2 score incorporates the following risk factors:
- Age: 60 years or older.
- Blood Pressure: Systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg.
- Clinical Features: Unilateral weakness, speech disturbance, or both.
- Duration of symptoms: ≥ 60 minutes or 10-59 minutes.
- Diabetes: Presence of diabetes mellitus.
2. Perform a focused neurological assessment. In patients presenting with TIA symptoms, the neurological exam should prioritize identifying localized neurological deficits and speech abnormalities. Assess cranial nerves, motor strength, sensation, coordination, and gait.
3. Assess the patient’s motor system. Evaluate reflexes, posture, and muscle strength. Monitor for signs of abnormal muscle tone such as spasticity, clonus (involuntary muscle spasms), and rigidity.
4. Conduct a cardiac examination. Perform a comprehensive cardiac assessment, including auscultation of the carotid arteries to detect carotid bruits (abnormal sounds indicating turbulent blood flow). Assess heart rate and rhythm for irregularities, murmurs, or rubs that may indicate underlying cardiac conditions.
5. Utilize a standardized stroke scale. The National Institutes of Health Stroke Scale (NIHSS) is the most commonly used tool for quantifying stroke severity and location. It should be administered in the context of a TIA to document neurological deficits.
6. Monitor vital signs and general status. Closely monitor vital signs for any abnormalities. Track changes in overall health status, including alertness, language comprehension, and ability to follow commands.
Diagnostic Procedures
1. Initiate initial diagnostic tests. The primary goal of initial testing is to rule out conditions that can mimic TIA symptoms, such as hypoglycemia, seizures, or cerebral hemorrhage. Obtain blood samples for coagulation studies, serum electrolyte levels, complete blood count, and perform a point-of-care blood glucose test.
2. Obtain an electrocardiogram (ECG). A 12-lead ECG is essential to evaluate for cardiac ischemia or arrhythmias. Atrial fibrillation, in particular, is a significant risk factor for TIA as it can lead to clot formation in the heart, which may embolize to the brain.
3. Prepare the patient for neuroimaging. Brain imaging is crucial and should ideally be performed within 24 hours of symptom onset. Non-contrast computed tomography (CT) of the head is often used initially to rule out hemorrhage, but magnetic resonance imaging (MRI) is preferred for its higher sensitivity in detecting ischemic changes.
4. Consider brain vessel imaging. Imaging of the cerebral vasculature is important to identify any arterial occlusions or stenosis. Options include Doppler ultrasound of the carotid arteries, CT angiography (CTA), or magnetic resonance angiography (MRA).
5. Investigate other potential causes if indicated. In specific cases, further investigations may be warranted. An electroencephalogram (EEG) can be used to assess for seizure activity, while a lumbar puncture may be indicated to evaluate for subarachnoid hemorrhage or central nervous system infections, particularly if these are suspected as alternative diagnoses.
6. Monitor for cardiac sources of embolism. Echocardiography, including transesophageal echocardiography (TEE), can help identify cardioembolic sources of TIA, such as atrial thrombi or patent foramen ovale. Inpatient telemetry or outpatient Holter monitoring may be considered if the etiology remains unclear after initial investigations to detect paroxysmal arrhythmias.
7. Draw blood for additional laboratory tests. Further blood tests may be ordered to investigate underlying causes and risk factors:
- Prothrombin Time (PT) and International Normalized Ratio (INR) to assess coagulation status.
- Lipid panel to evaluate cholesterol and triglyceride levels.
- Urine drug screen to detect substance abuse.
- Cardiac enzymes to rule out myocardial infarction if clinically indicated.
- Erythrocyte Sedimentation Rate (ESR) as a general marker of inflammation.
- Coagulation factors (fibrinogen, D-dimer) to assess for hypercoagulable states.
Nursing Interventions
Nursing interventions and comprehensive care are vital for patient recovery and stroke prevention following a TIA. This section outlines key nursing interventions for patients who have experienced a transient ischemic attack.
1. Initiate immediate stroke prevention strategies. Prompt medical intervention after a TIA significantly reduces the risk of an imminent stroke. The risk of stroke is highest in the days and weeks following a TIA, with approximately 20% of TIA patients experiencing a stroke within three months, and half of these occurring within the first two days.
2. Manage the underlying cause of the TIA. Treatment strategies should target the root cause of the TIA to prevent a subsequent, more severe stroke. These may include:
- Medications to reduce blood clot formation (antiplatelets, anticoagulants).
- Surgical interventions to address carotid artery stenosis.
- Stent placement (angioplasty) to open narrowed arteries.
3. Stabilize blood pressure within recommended parameters. While acutely lowering blood pressure is not always indicated, managing hypertension is critical for long-term stroke prevention. The American Heart Association guidelines suggest initiating antihypertensive medication for significantly elevated blood pressure (greater than 220/120 mm Hg or mean arterial pressure greater than 130 mmHg) to maintain adequate cerebral perfusion, unless there are coexisting cardiac or other medical conditions that necessitate more aggressive blood pressure control.
4. Administer medications promptly as prescribed. Following a TIA, timely medication administration is crucial to minimize stroke risk. Anticipated medication orders may include:
- Antiplatelet drugs:
- Aspirin
- Clopidogrel
- Anticoagulants:
- Heparin (often initially)
- Warfarin or direct oral anticoagulants (for long-term anticoagulation if indicated)
- Blood pressure medications (for hypertension management):
- Calcium channel blockers
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin II receptor blockers (ARBs)
- Diuretics
- Cholesterol-lowering medications (statins) to manage dyslipidemia.
5. Prepare the patient for potential surgical interventions. If carotid artery stenosis is moderate to severe, carotid endarterectomy (surgical removal of plaque) may be indicated. Patients with a patent foramen ovale (PFO) may require surgical or catheter-based closure to prevent paradoxical embolization.
6. Consider carotid angioplasty and stenting. Carotid angioplasty, often combined with stenting, is a less invasive procedure to open narrowed carotid arteries. It involves inserting a catheter with a balloon and stent to widen the artery and maintain patency.
7. Educate the patient on lifestyle modifications to reduce future TIA or stroke risk. Patient education is paramount for long-term prevention. Key teaching points include:
- Maintain blood pressure below 140/90 mmHg, or as directed by their healthcare provider.
- Maintain total cholesterol below 200 mg/dL, or as directed by their healthcare provider.
- Maintain optimal blood glucose levels if diabetic.
- Adhere to prescribed medications for hypertension, hyperlipidemia, and diabetes.
- Limit or eliminate heavy alcohol consumption.
- Maintain a healthy weight.
- Engage in regular physical exercise.
- Reduce sodium intake in the diet.
- Abstain from smoking.
8. Encourage specialist follow-up. Patients who experience a TIA should have timely follow-up appointments with their primary care physician. Referrals to specialists, such as neurologists or cardiologists, should be made if cardiac or neurological causes are identified or if further specialized management is needed.
Nursing Care Plans
Once nursing diagnoses are identified for a patient following a transient ischemic attack, nursing care plans are essential to prioritize assessments and interventions to achieve both short-term and long-term care goals. The following section provides examples of nursing care plans for common nursing diagnoses related to TIA.
Acute Confusion
Patients experiencing a transient ischemic attack may exhibit sudden, reversible confusion.
Nursing Diagnosis: Acute Confusion
Related to:
- Disease process of TIA
- Cerebral hypoxia due to reduced blood flow
- Ineffective cerebral tissue perfusion
- Potential brain injury or trauma from vascular event
As evidenced by:
- Altered psychomotor performance, such as restlessness or slowed movements.
- Difficulty initiating purposeful behavior.
- Cognitive dysfunction, including disorientation and memory impairment.
- Altered level of consciousness, ranging from mild drowsiness to lethargy.
- Neurobehavioral manifestations like agitation or irritability.
Expected outcomes:
- Patient will maintain orientation to person, place, and time throughout hospitalization.
- Patient will demonstrate appropriate motor behavior and cognitive responses.
Assessment:
1. Conduct a mental status assessment. A comprehensive neurological examination, including a mental status assessment, is crucial to evaluate the patient’s cognitive function. Orientation can be quickly assessed by asking the patient to state their name, current location, and the day of the week.
2. Assess the extent of impairment in communication, attention, and ability to follow directions. TIA can manifest as inattention, disorganized thinking, speech difficulties, and inability to follow simple commands. Detailed assessment in these areas is important.
3. Obtain information from caregivers or family about the patient’s baseline cognition. When possible, inquire with family members or caregivers about the patient’s usual cognitive function. This baseline information is invaluable for identifying acute changes and understanding the patient’s pre-TIA cognitive status, including any pre-existing memory issues, mood changes, or language difficulties.
Interventions:
1. Orient the patient to surroundings and activities frequently. Regular reorientation is vital for patients experiencing confusion. This helps promote safety, encourages cooperation with care, and builds a trusting nurse-patient relationship.
2. Provide a calm and quiet environment, minimizing unnecessary stimuli. Excessive environmental stimulation can exacerbate confusion, anxiety, and agitation in a confused patient. Reducing noise levels and dimming bright lights can create a more therapeutic environment.
3. Promote adequate sleep and rest. Sleep is essential for brain recovery following a TIA. Restorative sleep helps facilitate neural repair and can improve confusion and other cognitive symptoms.
4. Continuously monitor the patient’s level of consciousness and neurological status. While TIA symptoms are transient, the increased risk of stroke necessitates continuous monitoring of the patient’s level of consciousness and overall mental status. Prompt detection of changes allows for timely intervention and reduces the risk of complications.
Deficient Knowledge
Deficient knowledge related to transient ischemic attack can lead to delayed symptom recognition and increase the risk of future stroke.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Unfamiliarity with TIA symptoms and their significance.
- Lack of understanding about when to seek immediate medical attention for TIA symptoms.
- Misinformation regarding lifestyle factors that influence TIA risk.
- Misconceptions about TIA treatments and preventative measures.
- Sudden change in health status and the need for new health information.
- Poor health literacy, making it difficult to understand medical information.
- Anxiety, which can impede learning and information retention.
As evidenced by:
- Patient questions about TIA symptoms, causes, and treatments.
- Ineffective lifestyle modifications despite education.
- Recurrence of TIA or development of a major stroke due to lack of preventative knowledge.
- Nonadherence to recommended prevention and management strategies.
Expected outcomes:
- Patient will verbally explain the key differences between a TIA and a stroke.
- Patient will accurately describe the “F.A.S.T.” stroke symptom recognition acronym.
- Patient will identify and implement at least two lifestyle strategies to reduce their risk of future TIA or stroke.
Assessment:
1. Assess the patient’s current understanding of TIA and its mechanism. Begin by assessing what the patient already knows about TIAs. This baseline assessment helps tailor education to address knowledge gaps and misconceptions.
2. Evaluate the patient’s understanding of their personal risk factors. Determine if the patient understands how their chronic health conditions or lifestyle choices contribute to their TIA risk.
3. Identify any misconceptions or false beliefs about TIA. Explore the patient’s beliefs about TIA to differentiate between accurate knowledge and myths. It is crucial to emphasize that a TIA is not just a “minor” stroke but a serious warning sign of a potentially major stroke.
4. Assess the patient’s knowledge of TIA signs and symptoms. Educate the patient about both symptomatic and “silent” strokes. Emphasize that not all strokes present with obvious symptoms. Silent strokes, often detected incidentally on brain scans, are still significant and increase the risk of dementia, cognitive impairment, and future symptomatic strokes.
Interventions:
1. Teach the patient the F.A.S.T. acronym for stroke recognition. Educate the patient about the F.A.S.T. acronym (Face drooping, Arm weakness, Speech difficulty, Time to call emergency services). Explain that “time is brain” in the context of stroke and TIA, highlighting the importance of rapid response.
2. Explain the difference between a TIA and a stroke. Clarify that while often called a “mini-stroke,” a TIA is distinct from a stroke because the blood supply to the brain is temporarily interrupted, typically for less than five minutes, and does not cause permanent damage in most cases.
3. Educate the patient about healthy cholesterol levels and their importance. Since atherosclerosis and high cholesterol are major contributors to TIA, educate patients about their cholesterol levels and target ranges.
4. Have the patient verbalize preventative measures for TIA/stroke. Evaluate the effectiveness of patient teaching by having them list specific preventative steps to reduce TIA/stroke risk. These should include smoking cessation, dietary modifications (low-fat, low-sodium), regular exercise, and weight management.
5. Advise the patient about wearing a medical alert bracelet. For patients taking anticoagulants following a TIA, recommend wearing a medical alert bracelet or carrying identification indicating their medication use, due to the increased risk of bleeding.
Ineffective Cerebral Tissue Perfusion
Ineffective cerebral tissue perfusion associated with transient ischemic attack (TIA) results from interrupted blood flow and potential vasospasm, leading to insufficient oxygen supply to the brain tissue.
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)
Related to:
- Blood clot formation obstructing cerebral arteries.
- Reduced blood supply to the brain.
- Atherosclerosis and arterial narrowing.
- Sickle cell disease causing vaso-occlusion.
- Vasospasm of cerebral arteries.
As evidenced by:
- Change in mental status, including confusion, disorientation, or decreased alertness.
- Alteration in behavior, such as irritability or restlessness.
- Speech difficulty, including slurred speech or aphasia.
- Inability to communicate effectively.
- Motor weakness or paralysis on one side of the body.
- Change in sensory response, such as numbness or tingling.
Expected outcomes:
- Patient will maintain alertness and orientation to person, place, and time throughout hospitalization.
- Patient will not experience lasting motor weakness or paralysis following TIA.
- Patient will not experience a cerebrovascular accident (CVA) or stroke.
Assessment:
1. Rapidly assess F.A.S.T. signs and symptoms. Immediately assess for F.A.S.T. (Face, Arm, Speech, Time) symptoms. TIA symptoms may include facial drooping, arm weakness, and slurred speech. Document the “last known well” time, as this is critical for determining treatment options.
2. Determine neurovascular status. Assess for neurological deficits indicative of reduced cerebral blood flow, impacting vision, speech, language, motor, and sensory functions.
3. Monitor vital signs closely. Regularly monitor vital signs, including blood pressure in both arms to detect potential subclavian steal syndrome, which can cause significant blood pressure differences between arms.
4. Auscultate the heart and neck for abnormal sounds. Auscultate heart sounds for murmurs or arrhythmias and carotid arteries for bruits, which may indicate carotid artery stenosis.
5. Perform ECG to assess cardiac rhythm. Obtain an ECG to detect atrial fibrillation (AFib) or other arrhythmias, as AFib increases the risk of cardioembolic stroke.
6. Obtain neuroimaging scans as ordered. Neuroimaging, preferably MRI with diffusion-weighted imaging, is typically performed within 24 hours of symptom onset. CT head with CT angiography may be used if MRI is not feasible.
Interventions:
1. Maintain blood pressure within manageable parameters. Manage blood pressure as prescribed to optimize cerebral perfusion and prevent further arterial damage from hypertension.
2. Activate Rapid Response Team (RRT) if patient condition deteriorates. For patients at risk of progressing to a full stroke or experiencing worsening neurological status, activate the Rapid Response System to ensure immediate expert assessment and intervention to minimize mortality and morbidity.
3. Administer antiplatelet medications as prescribed to prevent clot formation. Administer prescribed antiplatelet medications such as aspirin or clopidogrel to reduce platelet aggregation and decrease the risk of clot formation and subsequent stroke.
4. Provide anticoagulants as ordered if indicated. Anticoagulants may be prescribed, especially for patients with atrial fibrillation or other conditions predisposing to clot formation. While anticoagulants do not dissolve existing clots, they prevent clot propagation and new clot formation.
5. Manage cholesterol levels through medication and lifestyle modifications. Address hypercholesterolemia, a major risk factor for TIA, with statin medications, dietary changes, and exercise to lower cholesterol levels.
6. Educate the patient about following a recommended heart-healthy diet. Provide dietary counseling on a low-fat, low-sodium, high-fiber diet rich in fruits, vegetables, and whole grains to reduce hypertension and hyperlipidemia risk.
7. Prepare the patient for possible surgical or interventional procedures. Prepare the patient for potential carotid endarterectomy or carotid angioplasty with stenting if indicated based on diagnostic findings.
Risk for Injury
Safety concerns and potential for injury are heightened in patients following a transient ischemic attack due to altered cognitive, sensory, and motor functions.
Nursing Diagnosis: Risk for Injury
Related to:
- Altered sensations (e.g., numbness, loss of proprioception).
- Motor weakness or paralysis affecting mobility and coordination.
- Impaired decision-making and judgment due to cognitive changes.
- Uncoordinated movements and gait disturbances.
- Paralysis affecting mobility and balance.
- Disorientation to person, place, and time.
- Inability to communicate needs or safety concerns.
- Impaired swallowing and risk of aspiration.
- Poor concentration and attention deficits.
As evidenced by:
A risk for diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected outcomes:
- Patient will utilize assistive devices appropriately and consistently as needed for mobility and safety.
- Patient will remain free from injury, falls, or wounds throughout hospitalization.
- Caregivers will create a safe environment and provide necessary assistance to ensure patient safety.
Assessment:
1. Determine the affected brain area and potential functional deficits. Identify the area of the brain affected by the TIA to anticipate potential safety risks. Right-sided brain involvement may lead to spatial-perceptual deficits, affecting judgment and concentration, increasing risks during activities like walking or driving. Left-sided brain involvement may cause communication and vision problems.
2. Observe the patient’s motor function and mobility. Assess for motor impairments such as gait disturbances, limb paralysis, lack of coordination, and unilateral weakness, all of which increase fall risk.
3. Assess sensory function and ability to perceive stimuli. Evaluate sensory function as impaired sensation can increase the risk of skin injury and breakdown due to inability to perceive pain, heat, or sharp objects.
4. Check the patient’s communication abilities. Assess communication abilities, as inability to express pain or safety concerns increases the risk of undetected injuries.
Interventions:
1. Orient the patient to their immediate surroundings. Enhance patient safety by ensuring they are familiar with their environment. Keep frequently used items, including the call bell, within easy reach.
2. Implement aspiration precautions for patients with dysphagia. For patients with swallowing difficulties, provide pureed diets and thickened liquids as needed. Assess chewing and swallowing abilities before meals, and monitor for signs of aspiration, such as coughing, gagging, or pocketing food.
3. Advise patients with vision changes on visual scanning techniques. For patients with hemianopia (visual field deficit), instruct them to scan their environment by moving their head from side to side to compensate for visual field loss and ensure awareness of obstacles and hazards.
4. Protect skin integrity and prevent pressure injuries. For patients with paralysis or sensory loss, prioritize skin protection. Maintain proper extremity alignment, turn the patient at least every two hours, check water temperature before bathing, and ensure medical devices and tubes are not causing pressure on the skin.
Unilateral Neglect
Unilateral neglect, while often less severe and transient in TIA patients, particularly if symptoms resolve quickly, can still occur, especially with right hemisphere involvement.
Nursing Diagnosis: Unilateral Neglect
Related to:
- Disease process of TIA affecting brain function.
- Cerebral hypoxia impacting cognitive and perceptual processing.
- Ineffective cerebral tissue perfusion to areas of the brain responsible for spatial awareness.
- Potential brain injury or trauma from transient ischemia.
As evidenced by:
- Hemianopsia or visual field cut.
- Weakness or paralysis on one side of the body.
- Numbness or sensory loss on one side of the body.
- Altered safety behavior related to the neglected side, such as bumping into objects on one side.
- Unilateral visuospatial neglect, ignoring stimuli on one side.
- Unawareness of the position of the neglected limb.
- Failure to notice people or objects approaching from the neglected side.
- Failure to move head or limbs in the direction of the neglected hemisphere.
Expected outcomes:
- Patient will demonstrate improved awareness of information and stimuli on both sides of the body.
- Patient will actively participate in self-care for both sides of the body and remain free from injury related to neglect.
Assessment:
1. Assess for signs and symptoms of unilateral neglect. Evaluate for behaviors indicative of unilateral neglect, such as neglecting self-care on one side of the body, not responding to stimuli from one side, or not visually attending to one side of their environment.
2. Assess the patient’s functional abilities and deficits related to neglect. Evaluate the impact of unilateral neglect on the patient’s ability to perform daily activities and identify specific functional deficits to guide intervention planning.
Interventions:
1. Implement fall precautions due to increased fall risk. Unilateral neglect significantly increases fall risk, particularly with right hemisphere damage. Ensure the bed is in the lowest position with bed alarms activated. Remind the patient to call for assistance when getting out of bed or chair.
2. Collaborate with rehabilitation specialists for comprehensive care. Consult with physical therapists (PT), occupational therapists (OT), speech-language pathologists (SLP), neuropsychologists, and other rehabilitation professionals to develop a comprehensive plan to address unilateral neglect and promote attention to the affected side.
3. Modify the environment to encourage interaction with the neglected side. Position the bed so that healthcare staff approach the patient from the unaffected side initially, but encourage interaction with the neglected side. Place personal items and necessary equipment within the patient’s visual field on the unaffected side to promote awareness and engagement with that side.
4. Educate family and caregivers about unilateral neglect. Educate family members and caregivers about the manifestations and implications of unilateral neglect, even if transient, to ensure patient safety, comfort, and consistent support in addressing neglect-related challenges.
References
- Nursing Diagnosis: Acute Confusion
- Nursing Diagnosis: Deficient Knowledge
- Nursing Diagnosis: Ineffective Tissue Perfusion
- Nursing Diagnosis: Risk for Injury
- Nursing Interventions
- Nursing Care Plans
- Stroke (Cerebrovascular Accident) Nursing Diagnosis & Care Plan
- Subjective vs. Objective Data in Nursing
- Vertigo Nursing Diagnosis & Care Plan
- Confusion Nursing Diagnosis & Care Plan
- Smoking Nursing Diagnosis & Care Plan
- Substance Abuse Nursing Diagnosis & Care Plan
- Obesity Nursing Diagnosis & Care Plan
- Atrial Fibrillation Nursing Diagnosis & Care Plan
- Obstructive Sleep Apnea Nursing Diagnosis & Care Plan
- Peripheral Vascular Disease Nursing Diagnosis & Care Plan
- Migraine Headache Nursing Diagnosis & Care Plan
- Diabetes Mellitus Nursing Diagnosis & Care Plan
- Hypertension Nursing Diagnosis & Care Plan
- Sickle Cell Anemia Nursing Diagnosis & Care Plan
- Hypoglycemia Nursing Diagnosis & Care Plan
- Seizure Nursing Diagnosis & Care Plan
- Aspirin Nursing Considerations
- Heparin Nursing Considerations
- Alzheimer’s Disease/Dementia Nursing Diagnosis & Care Plan
- Altered Mental Status Nursing Diagnosis & Care Plan
- Tetralogy of Fallot Nursing Diagnosis & Care Plan
- Safety Nursing Diagnosis & Care Plan
- Acute Pain Nursing Diagnosis & Care Plan
- Impaired Skin Integrity Nursing Diagnosis & Care Plan
- Risk for Falls Nursing Diagnosis & Care Plan
- Traumatic Brain Injury Nursing Diagnosis & Care Plan
