Cerebral Vascular Accident

Pathophysiological Process: A cerebral vascular accident, also known as a stroke, is a sudden loss of consciousness followed by paralysis, caused by bleeding into the brain, formation of a blood clot that blocks an artery, or rupture of an artery in the brain that causes bleeding into the subarachnoid space. Most commonly, a clot is the cause. Other plaque material or pieces of blood clots that travel to the brain from other sources can also cause a stroke. Another cause of a stroke is related to hardening of the arteries, which allows fatty deposits to accumulate inside the arteries causing a blockage that will travel and will block a part of the brain. The risk of stroke includes having a history of very high blood pressure, smoking, diabetes, leukemia; aplastic anemia; brain tumors; gout; high cholesterol, and birth control pills use.

Three expected Nursing Diagnoses:

Three appropriate interventions for each diagnosis:

1. Risk for aspiration related to impaired swallowing.
   1. Keep head of bed elevated when feeding and for at least an hour afterward.
   2. Auscultate lung sounds frequently and before and after feedings; note any new onset of crackles or wheezes.
   3. When feeding client, watch for signs of impaired swallowing or aspiration, including coughing, choking, spitting food, or excessive drooling.
2. Impaired Swallowing related to neuromuscular dysfunction.
   1. Determine the client's readiness to eat. The client needs to be alert, able to follow instructions, able to hold the head erect, and able to move the tongue in the mouth.
   2. Observe for signs associated with swallowing problems (e.g., coughing, choking, spitting of food, drooling, difficulty handling oral secretions, double swallowing or major delay in swallowing, or watering eyes.)
   3. Position the client upright at a 90-degree angle with the chin tucked forward at a 45-degree angle.
3. Disturbed body image related to paralysis.
   1. Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle.
   2. Do not ask client to explore feelings unless he has indicated a need to do so.
   3. Encourage the client to make own decisions, participate in plan of care, and accept both inadequacies and strengths.

Major Concepts related to client's age/developmental level:

1. Erikson: Generativity vs. Stagnation: Erikson refers to generativity as an adult's ability to look outside oneself and care for others. It is a concern for the next generation. Generativity is an extension of love into the future, but this love is far more mature and unselfish during this stage. Generativity is a love that is given regardless of whether it is reciprocated. Stagnation is the exact opposite. It is caring for no-one and being self-absorbed. If a favorable balance is achieved during this stage, then the virtue care is developed.
2. Piaget: The formal operational stage is the fourth and final stage in Piaget's theory. It begins at approximately 11 to 12 years of age, and continues throughout adulthood; although Piaget does point out that some people may never reach this stage of cognitive development. The formal operational stage is characterized by the ability to formulate hypotheses and systematically test them to arrive at an answer to a problem. The individual in the formal stage is also able to think abstractly and to understand the form or structure of a mathematical problem. Another characteristic of the individual is their ability to reason contrary to fact. That is, if they are given a statement and asked to use it as the basis of an argument they are capable of accomplishing the task. For example, they can deal with the statement "what would happen if snow were black".
3. Kohlberg: Postconventional: the attainment of true morality. Think in rational terms, valuing the will of the majority and the welfare of society. His contention is that the attainment of Postconventional moral reasoning is associated with optimal personal and social adjustment. A sense of obligation to law because of one's social contract to make and laws for the welfare of all and for the protection of all people's rights. A feeling of contractual commitment, freely entered upon, to family, friendship, trust, and work obligations.