Help With A Nursing Dx

NurseyBaby'05, BSN, RN · Apr 7, 2005

Think of your patho with stroke. What is it about hypertension that puts your patient at a risk for CVA? If the arteries narrow the heart is going to have to work harder to pump out oxygenated blood to the rest of the body. Hope this info points you in the right direction!:)

NurseyBaby'05, BSN, RN · Apr 7, 2005

Welcome to allnurses!:balloons:

lilrednurse · Apr 7, 2005

Think of your patho with stroke. What is it about hypertension that puts your patient at a risk for CVA? If the arteries narrow the heart is going to have to work harder to pump out oxygenated blood to the rest of the body. Hope this info points you in the right direction!:)

Thanks. Yes, I do understand how they are at risk for the stroke, but I do not know how to write the Nursing Dx itself b/c it has to be from the Nanda List and that is the problem I am having.. In other words can I put Risk for Stroke is not a Nursing DX..

Any suggestions?

Thanks for the Help and the Welcome..

PamRNC · Apr 7, 2005

Cerebrovascular Accident (CVA)

What kind of stroke is your pt at risk for? Hemorrhagic or Thrombic?

Could they be at risk for injury r/t pressure damage, chemical exposure, altered clotting factors, altered mobility, AEB: SBP > 150, smoking 2ppd/20yrs, coumadin use, INR = 4.8, and bedridden?

Sorry if the format is off, haven't actually had to write a NANDA in a while, keep in mind though that Hx of prior stroke is a risk factor for a repeat stroke.

You may even have opportunities for collaborative diagnoses.

lilrednurse · Apr 7, 2005

Cerebrovascular Accident (CVA)
What kind of stroke is your pt at risk for? Hemorrhagic or Thrombic?
Could they be at risk for injury r/t pressure damage, chemical exposure, altered clotting factors, altered mobility, AEB: SBP > 150, smoking 2ppd/20yrs, coumadin use, INR = 4.8, and bedridden?
Sorry if the format is off, haven't actually had to write a NANDA in a while, keep in mind though that Hx of prior stroke is a risk factor for a repeat stroke.
You may even have opportunities for collaborative diagnoses.

Ok, Thanks for some good info!

I would say Thrombolic, b/c that would be associated with the arteries b/c occluded and blood flow to the area diminished. so is TIA considered injury ...

THAnks again!

PamRNC · Apr 7, 2005

TIA is actually a prescursor to stroke. Apparently many pts have TIAs long before they have a full-blown stroke, and usually blow them off/ignore them.

lilrednurse · Apr 7, 2005

TIA is actually a prescursor to stroke. Apparently many pts have TIAs long before they have a full-blown stroke, and usually blow them off/ignore them.

The client has never had a stroke.... So maybe a TIA would be appropriate..Whatever the case I have several good nursing care plan books and none of them address any kind of stroke as a nursing diagnosis for hypertensive clients...

So would injury be a way of stating CVA or TIA without usingthe actual medical diagnosis jof CVA or TIA

tridil2000, MSN, RN · Apr 7, 2005

Ok, Thanks for some good info!
I would say Thrombolic, b/c that would be associated with the arteries b/c occluded and blood flow to the area diminished. so is TIA considered injury ...
THAnks again!

potential for... altered neuro status r/t hypertension

goal... no nuero deficits/changes. if identified, consult physician immediately.

1. check bp every 1-2 hours, including mean.

(malignant htn = dbp>140/accelerated htn = dbp>120)

2. keep meanbp

3. monitor neuro status every 1-2 hours

speech

gait

facial symmetry

perl

hand grasps

4. administer htn meds

5. decrease icp

discourage straining

keep hob ^ 30'

report frequent coughing and consult physician regarding cough medication

6. monitor pt/ptt, as pt's with prolonged times have increased risk for cerebral bleeding

(if the pt is icu, you would include icp and cpp and maybe abgs )

VickyRN, MSN, DNP, RN · Apr 7, 2005

Cerebrovascular Accident (CVA)
What kind of stroke is your pt at risk for? Hemorrhagic or Thrombic?
Could they be at risk for injury r/t pressure damage, chemical exposure, altered clotting factors, altered mobility, AEB: SBP > 150, smoking 2ppd/20yrs, coumadin use, INR = 4.8, and bedridden?
Sorry if the format is off, haven't actually had to write a NANDA in a while, keep in mind though that Hx of prior stroke is a risk factor for a repeat stroke.
You may even have opportunities for collaborative diagnoses.

These are GREAT suggestions. Just remember that any "Risk for..." nursing dx does not have "AEB." The rest of the format is great. My suggestion - Write "Risk for Injury (ischemic CVA) r/t pressure damage, chemical exposure, altered clotting factors, etc..."

VickyRN, MSN, DNP, RN · Apr 7, 2005

potential for... altered neuro status r/t hypertension
goal... no nuero deficits/changes. if identified, consult physician immediately.
1. check bp every 1-2 hours, including mean.
(malignant htn = dbp>140/accelerated htn = dbp>120)
2. keep meanbp
3. monitor neuro status every 1-2 hours
speech
gait
facial symmetry
perl
hand grasps
4. administer htn meds
5. decrease icp
discourage straining
keep hob ^ 30'
report frequent coughing and consult physician regarding cough medication
6. monitor pt/ptt, as pt's with prolonged times have increased risk for cerebral bleeding
(if the pt is icu, you would include icp and cpp and maybe abgs )

These are EXCELLENT interventions. May I suggest the following for the nursing diagnosis (most current NANDA-approved) - "Risk for Disturbed Sensory Perception (global) r/t neurological trauma 2nd hypertension and occlusion of blood flow to brain tissues"

Other possible high-priority nursing diagnosis:

"Risk for Ineffective Cerebral Tissue Perfusion r/t interruption of blood flow"

Nrs_angie, BSN, RN · Apr 9, 2005

I am working on my major case study.. My instructor wants me to work through a nursing dx that will suggest the client is at risk for a stroke. Client has HTN. But what Nanda list nursing dx fits that... I don't think I can put Risk for Stroke b/c stroke is a medical dx. ANYONE CAN HELP WITH THIS? I appreciate it... I have to finish this by tommorrow... Thursday.

I guess this post is coming to you a little late considering you needed it by thursday. I would say to look at the 'ineffective cerebral tissue perfusion r/t decreased blood flow.