Question

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client?

Answer 1

Answer: Maintain an open airway.

Explanation:

The head-tilt chin-lift is the most reliable method of opening the airway. The simplest way of ensuring an open airway in an unconscious patient is to use a head tilt chin lift technique, thereby lifting the tongue from the back of the throat. The airway is the most important priority in the management of the severely injured patient. It is essential to open and clear the airway to allow free access of air to the distal endobronchial tree. ... Once the airway is maintained, it is important to ensure adequate oxygenation and ventilation through the airway.

Answer 2

Answer:

The major nursing care planning goals for the patient and family may include:

Improve mobility, Avoidance of shoulder pain, Achievement of self-care, Relief of sensory and perceptual deprivation, Prevention of aspiration, Continence of bowel and bladder, Improved thought processes, Achieving a form of communication, Maintaining skin integrity, Absence of complications.

Explanation:

Positioning. Position to prevent contractures, relieve pressure, attain good body alignment, and prevent compressive neuropathies.

Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.

Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.

Prevent edema. Elevate affected arm to prevent edema and fibrosis.

Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.

Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.

Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and begin walking as soon as standing balance is achieved.

Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.

Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual perception is intact.

Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in teaching alternate swallowing techniques.

Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.

Be consistent in patient’s activities. Be consistent in the schedule, routines, and repetitions; a written schedule, checklists, and audiotapes may help with memory and concentration, and a communication board may be used.

Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.