Stroke
A stroke, or cerebrovascular accident (CVA), is a medical emergency that occurs when blood flow to a part of the brain is disrupted, leading to cell damage and potentially irreversible consequences. Prompt recognition and immediate medical attention are paramount to minimize the long-term effects of a stroke.
Common symptoms of a stroke include sudden numbness or weakness on one side of the face or body, difficulty speaking or understanding speech, and severe headaches. There are two primary types of strokes: ischemic, caused by a blockage in a blood vessel, and hemorrhagic, resulting from bleeding within the brain.
Risk factors for strokes include high blood pressure, smoking, diabetes, and a sedentary lifestyle. Age and family history also contribute to an individual's susceptibility. Preventive measures include maintaining a healthy lifestyle, managing chronic conditions, and seeking medical advice for risk factor modification.
Effective treatment for strokes often involves restoring blood flow to the affected area. Thrombolytic medications, clot retrieval procedures, and rehabilitation efforts are common approaches to improve outcomes and regain functionality.
Ineffective airway clearance
Ineffective airway clearance is a condition where the natural ability to clear mucus and other secretions from the respiratory tract is compromised, posing a significant threat to respiratory health. This condition can result from various factors, including respiratory infections, chronic lung diseases, or neuromuscular disorders, hindering the body's ability to maintain a clear and unobstructed airway.
Individuals experiencing ineffective airway clearance may manifest symptoms such as persistent coughing, difficulty breathing, and increased susceptibility to respiratory infections. Left untreated, this condition can lead to more severe complications, including respiratory distress and pneumonia.
Ineffective airway clearance related to the buildup of sputum (due to weakness, loss of cough reflex)
Goal:
* Patients are able to maintain a patent airway
Expected outcomes:
* Vesicular breath sounds
* Normal respiratory rate
* No signs of cyanosis and pallor
* No sputum
Nursing Interventions Ineffective airway clearance for Stroke
* Auscultation of breath sounds
* Measure vital signs
* Give the semi-Fowler position as needed (do not conflict with other nursing problems)
* Perform suction mucus and plug the OPA if decreased consciousness
* When it is possible to do chest physiotherapy and breathing exercises
* Collaboration:
o Oxygen delivery
o Laboratory: Analysis of blood gases, complete blood etc.
o Giving medication as needed.
Bibliography:
1. Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., ... & American Heart Association Stroke Council. (2018). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50(12), e344-e418. doi:10.1161/STR.0000000000000211
2. Hemphill, J. C., Greenberg, S. M., Anderson, C. S., Becker, K., Bendok, B. R., Cushman, M., ... & Smith, E. E. (2015). Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46(7), 2032-2060. doi:10.1161/STR.0000000000000069
3. Volsko, T. A. (2018). Airway Clearance Therapy: Finding the Evidence. Respiratory Care, 63(6), 819-827. doi:10.4187/respcare.06296
4. Hess, D. R. (2007). The evidence for secretion clearance techniques. Respiratory care, 52(10), 1386-1394. PMID: 17894901
