Nursing Assessment and Care of a Patient Following a CVA Essay

Nursing Assessment and Care of a Patient Following a CVA - Essay ExampleHe has not passed urine since admission. He exhibits some paresis, and is leaking saliva at the right side of his mouth. Two possible nurse diagnosis related to to this patients condition include Risk for mark related to impaired swallowing secondary to cerebrovascular accident Risk for falls related to bodily weakness, secondary to CVA. This paper shall discuss the patients assessment information and handlings which can be implemented for the patient. Body Assessment 1 Risk for aspiration related to impaired swallowing secondary to cerebrovascular accident. This nursing diagnosis relates to this patients assessment data because the patients swallowing reflex is compromised and he is as well un satisfactory to control his saliva string up into his tracheobronchial passages. As a result, his saliva getting into his bronchial tubes and on to his lungs is a significant possibility. Two priority nursing interv entions to address the problem includes clear secretions from the mouth or throat with a tissue paper of gentle suck and maintain side-lying position. Clear secretions from the mouth or throat with a tissue of gentle suction This intervention would involve the regular checking of the patients mouth for saliva build-up, clearing such build-up with a tissue or via gentle suction. Preventing saliva build-up in the mouth prevents the saliva from flux down the throat and into the bronchial tubes and lungs, on that pointby preventing aspiration (Carpenito-Moyet, 2008). Moreover, cleaning of the oral cavity would as well help prevent the build-up of bacteria. Since the patient manifests right-sided hemiparesis, there is a need to assist the patient in controlling the saliva flow, and prevent such from flowing unconsciously down his throat. alter and suctioning the mouth is suitable because it can easily reduce saliva flow and it can be managed well as an independent nursing interventi on by the nurse (Carpenito-Moyet, 2008). Cleaning and suctioning the patients mouth would also prevent bacteria build-up and prevent any additional wellness issues, like aspiration pneumonia, which may arise from the patients current condition. Suctioning may however also instigate dryness in the patients mouth, therefore, the suctioning must not be excessive. Suctioning may also cause oral and throat irritation. If not properly and carried out under sterile conditions, it may promote bacteria build-up (Carpenito-Moyet, 2008). Suctioning must therefore be carried out gently and with the proper lotion of sterile techniques. The application of suctioning among patients whose swallowing reflexes have been compromises has been proven an effective practice by various researches. In a paper by Coffman, et.al., (2007) the authors sought to investigate the benefits of using cuffed tracheotomy tubes in order to suction patients saliva. The authors were able to establish a significant decre ase in aspirate with the use of intermittent suction. In effect, the authors think that the use of suctions can reduce the bump of aspiration and therefore reduce the patients risk for aspiration. This was also echoed in the study by Yoon and Steele (2007), where the authors highlighted the fact that proper oral care is an effective dash of reducing incidents of aspiration pneumonia and bacterial colonization in the mouth. Evaluation criteria to establish efficacy of the intervention is