impaired physical mobility nurse diagnosis

The Glasgow Coma Scale (GCS) is useful for assessing the state of consciousness

Family predisposition for arteriovenous malformation (AVM).

valve prosthesis, and atrial fibrillation.

cardiac valve diseases, such as those that may result from rheumatic fever,.

high serum cholesterol or triglycerides.

Positive Kernig’s or Brudzinski’s sign indicates meningeal irritation.

Dorsiflexion of the great toe with Fanning of the other toes is a positive sign.

To check for Babinski’s response, stroke the lateral aspect of the sole of the foot (from the heel to the ball of the

superficial reflexes, and positive Babinski’s sign also may be present.

Hyperactive deep tendon reflexes (DTRs), decreased.

hemorrhagic retinal areas on ophthalmic examination.

As the spinal cord depression resolves, tone becomes more normal and hyperactive reflexes appear. Initially, the patient usually has flaccid paralysis. Similarly, obstruction of an anterior cerebral artery can cause bilateral symptoms, as can severe hemorrhage or multiple emboli. When the stroke affects the cranial nerves, the symptoms of cranial nerve deficit occur on the same side as the injury site. Thus, a stroke in the left side of the brain results in symptoms in the right arm and leg.

Sudden, severe headache with no known causeĬlassically, symptoms occur on the side of the body opposite the injured area.

Sudden difficulty walking, dizziness, loss of balance or coordination.

Sudden visual disturbances in one or both eyes.

Sudden confusion, difficulty in speaking or understanding.

Sudden numbness or weakness in the face, arms or legs, especially on one side of the body.

Other types of ischemic strokes are caused by hyperglycemia and hyperinsulinemia, arterial dissection, arteritis, and drug abuse.īecause of the narrow window of opportunity to reverse permanent neurological damage, it is important to teach patients not to ignore symptoms and to call 911 immediately in the following cases:.

Cardioembolic strokes result from atrial fibrillation, valvular disease, or ventricular thrombi.

Thrombotic strokes in small vessels are typically due to plaque, diabetes mellitus, or hypertension.Thrombotic and embolic strokes in large vessels result from hypoperfusion, hypertension, and emboli that migrate from large arteries to distal branches.Hypoxia of any cause can also precipitate this syndrome. Causes of circulatory failure include hypovolemia, hypotension, and cardiac arrhythmias.

Ischemic strokes caused by systemic hypoperfusion are usually the result of decreased cerebral blood flow due to circulatory failure. Most embolic strokes are cardiogenic and the result of emboli caused by valvular heart disease or when the heart is in atrial fibrillation. Thrombi in small penetrating arteries cause “lacunar” strokes. Most thrombotic strokes are caused by blockage of large vessels due to atherosclerosis. The resulting ischemia, if prolonged, causes necrosis of brain tissue, cerebral edema, and increased intracranial pressure. Thrombosis or embolism results in interruption of blood supply to brain tissue. Ischemic stroke has three main mechanisms: Types of strokesĭisturbance of blood flow to the brain caused by partial or complete occlusion of a blood vessel, with temporary or permanent effects. This may be due to rupture of one or more blood vessels supplying the brain or loss of cerebral blood flow, which often results from hypoperfusion or a reduction in O2 supply. 7.5 Deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs Stroke:īefore learning nursing care plans stroke, we learn about some important facts about strokeĬell death of brain tissue due to interruption of blood supply to parts of the brain, resulting in neurological deficits that cause disabilities such as paralysis or speech disorders.Ī stroke, cerebrovascular accident (CVA) or cerebral infarction is the sudden interruption of O2 supply to the brain.

Impaired physical mobility nurse diagnosis