Medical Diagnosis: Cerebral Infarction

Medical Diagnosis: Cerebral Infarction

1. Risk for aspiration AEB difficulty swallowing R/T dysphagia

   • Assesment: - Difficultly intiating swallowing -- Dysphagia pureed diet- deficits from stroke- Pt reports of diffculty eating--impaired function on neuro exam
   • Labs: - MRI confirming stroke***--Swallow test (speech therapist)
   • Interventions: --Monitor RR, depth, and effort-note any signs of aspiration (wet voice, dyspnea, cough, cyanosis, wheezing, hoarseness, foul smelling sputum or fever) --Monitor LOC --Assess cough, gag reflex, swallowing ability before meals -Sit up patient for all meals 90 degress --HOB remain elevated 30 degrees --Leave pt reaming upright 30 minutes after each meal --If indicated, consult with the practitioner regarding the need to change oral medications to other routes . Discuss with the pharmacy available types of oral medications that would be easier for the patient to swallow. --Obtain a dietary consult as indicated --Obtain a speech therapy consult for swallowing assessment and testing as indicated --Obtain a social services consult as indicated --Obtain an occupational therapy consult as indicated
   • Meds: N/A

2. Risk for falls AEB hx of falls R/T unsteady gait

   • Assesment: Impaired function on neuro exam--unsteady gait-- difficulty with spatial reasoning--blurred vision--AAOx2--confusion--frequent redirection/reoreintation--visual field defect
   • Labs: MRI confirming stroke***
   • Meds: Lisinopril
   • Interventions: -Standard fall precautions (call light, bed kept at lowest level,- 1:1 sitter if needed) -Pt will be assisted with appropriate number of team members during transfer and ambulation -Pt gait, balance, and level of fatigue will be monitor before, during, and after ambulation -If additional occupation or physical therapy consult needed, will be obtained