The Client with Alterations in Neurological Function

ALZHEIMER’S DISEASE/DEMENTIA

Alzheimer’s disease is a slowly progressive disease that is characterized by stages of declining memory, cognitive and behavioral functioning. Approximately 5 million Americans have been diagnosed with Alzheimer’s disease, with a predicted increase to 7.7 million by 2031 It is the most common form of dementia and affects more women than men (possibly because women live longer), and the risk for and incidence of this disease is slightly higher in African Americans and Hispanics than in other populations.

Although the cause of Alzheimer’s disease is unknown, several uncontrollable risk factors are associated with the development of the disease, including age, family history/genetics, and gender. Age is one of the most important factors in the development of Alzheimer’s disease. The chance of developing Alzheimer’s doubles every 5 years in individuals older than 65 years. By the time an individual reaches the age of 85, there is a 50% chance that they will develop the disease. It can, however, rarely affect individuals younger than the age of 40.

The second risk factor is family and genetics. An individual who has a first-degree relative’a sister, brother, or parent’with Alzheimer’s is at a greater risk for developing the disease. The risk increases even more if more than one family member has the illness. The gene identified that carries the risk of Alzheimer’s disease is apolipoprotein E-e4 (APOE-e4). This form of APOE gene is one of three in the body and is responsible for the development of proteins in the blood that carry cholesterol The presence of APOE-e4 increases the risk of developing the disease however, the presence of this gene does not mean development of the disease is certain. Individuals who inherit a copy of the APOE-e4 gene are simply at increased risk for developing Alzheimer’s. If the individual inherits two copies of the gene (one from each parent), he or she has an even greater risk of developing the disease; however, again inheriting the APOE-e4 gene is not a guarantee that the individual will develop Alzheimer’s disease.

The last uncontrollable risk factor is gender. Women are at a higher risk of developing the disease because they usually live longer than men. Other potential risk factors are serious head injury, high blood pressure, poorly controlled diabetes, high cholesterol, obesity, and overall poor health during the aging process. A higher incidence of obesity, diabetes, and high cholesterol also increases a woman’s likelihood of developing Alzheimer’s.

Alzheimer’s disease is a chronic, progressive disease that affects the brain structures. Changes that occur in the brain are the development of neurofibrillary tangles, amyloid or neurotic plaques, and the loss of connection between neurons. The plaques develop initially in the areas of the brain responsible for memory and cognitive functioning. Over time the plaques develop in the cerebral cortex in the areas that control language and reasoning.

The onset of Alzheimer’s disease usually occurs between 50 and 60 years of age, but may affect people as early as age 40. In the early stage of Alzheimer’s disease, the individual may appear healthy, but experiences forgetfulness, short-term memory loss, mild impairment in judgment, and difficulty in deciphering or calculating numbers. Loss of initiative and interest, decreased ability to make judgment, and geographic disorientation are also experienced. These clinical manifestations develop over time; the initial memory deterioration is so subtle that it may not be noticed. The timeframe for the early stage is 2 to 4 years.

In the middle or moderate stage, the clinical manifestations of the disease become more pronounced. The client may experience inability to recognize close family or friends, impairment of cognitive functions, disorientation to person, place, and time, agitation, confusion, possible paranoia hallucinations, and delusions. Affected individuals may wander away from their regular environment and become lost; they may experience mood swings and exhibit aggressive behaviors. The individual’s lack of concern about personal hygiene and appearance also become more noticeable.

In the final stage, clients are unable to interact with or respond to their environment. They become bedridden and are totally dependent upon others for activities of daily living. They are unable to carry on a conversation and have no recognition of self or others. This stage lasts until the individual dies, which usually occurs about 14 years after diagnosis.

There is no cure for Alzheimer’s disease. Treatment focuses on retaining memory, cognitive and physical functioning, and slowing the progression of the disease. Drug therapy consists of four medications that have been approved by the United States Food and Drug Administration: donepezil, rivastigmine, galantamine, and memantine. These medications regulate the neurotransmitters that transmit information from neuron to neuron. They are thought to help maintain cognitive and memory functioning and may control some of the behavioral symptoms. Other medications may be used to control the symptoms of insomnia, agitation, depression, and anxiety.

This care plan focuses on the adult client with Alzheimer’s disease who has been hospitalized. However, much of the information is also applicable to clients with dementia who are receiving follow-up care in an extended care facility or home setting.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Maintain cognitive functioning as long as possible

2. Have a decline in number of wandering incidents

3. Have minimal episodes of aggressive behavior

4. Avoid behaviors that may harm self or others

5. Participate in activities of daily living

6. Engage in appropriate social interaction with others

7. Engage in a regular exercise program

Nursing Diagnosis RISK FOR VIOLENCE: SELF-DIRECTED OR OTHER-DIRECTED NDx

Definition: At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to self and/or others

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of being anxious	Altered perception of reality; frequently expresses anger or frustration; changes in sleep and rest patterns; changes in coping skills; becoming increasingly more aggressive; mood swings

RISK FACTORS:

• Impaired cognitive function

• Inability to appropriately handle frustration

• Impaired assessment of the environment

DESIRED OUTCOMES: The client will not experience violence to self and/or others as evidenced by:

a. No personal injury or injury to others

b. No demonstration of aggressive behavior

c. No verbal outburst

d. No violation of others personal space

NOC OUTCOMES: Aggression control; cognitive ability; mood equilibrium; risk control

NIC INTERVENTIONS: Mood enhancement; environment management; violence prevention; behavior modification

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis SELF-CARE DEFICIT: DRESSING, BATHING, FEEDING, AND TOILETING NDx

Definition: Impaired ability to perform or complete bathing/hygiene/grooming/feeding activities for oneself

Related to:

• Inability to make decisions

• Loss of cognitive understanding

• Altered thought processes

• Difficulty in processing information

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Inability to determine what to wear; inability to feed self; inability to run bath water or clean self after micturition or defecation

DESIRED OUTCOMES: The client will be able to perform activities of daily living as evidenced by:

a. Ability to appropriately dress and groom self with no or minimal assistance

b. Ability to feed self with no or minimal assistance

c. Ability to care for personal hygiene with no or minimal assistance

NOC OUTCOMES: Self-care: bathing, grooming, eating, personal hygiene

NIC INTERVENTIONS: Self-care assistance: bathing, grooming, feeding, personal hygiene

NURSING ASSESSMENT

	RATIONALE
Assess client’s current self-care habits.	Provides a baseline of client’s ability and where interventions should be implemented
Assess client’s cognitive and physical ability to perform selfcare habits.	When a client’s cognitive abilities are impaired, the client is unable to determine self-care needs.

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis CHRONIC CONFUSION NDx

Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; manifested by disturbances of memory, orientation, or behavior

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Inaccurate interpretation of environment and time; memory loss; altered mood states (e.g., lability, hostility, irritability, inappropriate affect); inability to make decisions or problem solve; changes in attention span; disorientation; inappropriate social behavior; progressive cognitive impairment

RISK FACTORS:

• Physiologic changes from progression of Alzheimer’s disease

DESIRED OUTCOMES: The client will:

a. Remain calm and display minimal aggressive behaviors

b. Have limited disorientation to person, place, and time

NOC OUTCOMES: Cognition; distorted thought; self-control; safety behavior; information processing

NIC INTERVENTIONS: Dementia management; environmental management; behavioral management

NURSING ASSESSMENT

	RATIONALE
Assess for episodes of disorientation to person, place, and time, episodes of inappropriate behavior, impaired decision-making ability, impaired memory and judgment, delusions, impaired attention span.	Early recognition of signs and symptoms of confusion allows for prompt intervention.

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMPAIRED HOME MAINTENANCE NDx

Definition: Inability to maintain a safe and growth-promoting immediate environment

Related to:

• Degeneration in cognitive functioning

• Inability to make decisions

CLINICAL MANIFESTATIONS:

Subjective	Objective
Expression of difficulty in maintaining household; family member request for assistance in caring for the client in their home	Household temperature too hot or too cold; inability to completely dress self or choose clothing to wear; lack of personal hygiene; offensive body odors; disorganized surroundings; becomes disoriented in familiar surroundings; tendency to wander; inability to provide appropriate meals for self

RISK FACTORS:

• Inappropriate decision-making

• Deteriorating cognitive functioning

• Decreased fine and/or gross motor skills

• Memory deficits

DESIRED OUTCOMES: The client will not experience impaired home maintenance as evidenced by:

a. Maintains a clean and safe home

b. Dresses with appropriate clothing

c. Maintains adequate nutritional status

NOC OUTCOMES: Family functioning; safety behavior; home physical environment; self-care: instrumental activities of daily living

NIC INTERVENTIONS: Family support; self-care assistance; home maintenance assistance

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis RISK FOR CAREGIVER ROLE STRAIN NDx

Definition: Difficulty in performing family caregiver role

Related to:

• Duration of care

• Complexity of care

• Level of illness experienced by the client

CLINICAL MANIFESTATIONS:

RISK FACTORS:

• Financial status

• Support for the caregiver

• Caregiver’s age

• Caregiver’s health

DESIRED OUTCOMES: The caregiver will not experience role strain as evidenced by:

a. Feelings of being supported in the care of the client

b. Maintenance of his/her own physical and mental health

c. Accessing community resources and respite care

d. Expresses self-confidence in dealing with the complexity of client care

NOC OUTCOMES: Caregiver well-being; caregiver-patient relationship; caregiver role endurance

NIC INTERVENTIONS: Caregiver support

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

ADDITIONAL NURSING DIAGNOSES

IMPAIRED SOCIAL INTERACTIONS NDx

Related to:

• Alterations in cognition

• Memory deficits

• Impaired judgment

• Inappropriate, hostile, and bizarre behaviors

DISTURBED SENSORY PERCEPTION NDx

Related to:

• Altered sensory integration

• Altered sensory reception

• Excessive environmental stimuli

GRIEVING NDx

CEREBROVASCULAR ACCIDENT

A cerebrovascular accident (CVA, stroke, brain attack) is the result of an interruption in the blood flow in areas of the brain and is characterized by the sudden development of neurological deficits that last for at least 24 hours. These deficits range from mild symptoms such as tingling, weakness, and slight speech impairment to more severe symptoms such as hemiplegia, aphasia, dysphagia, loss of portions of the visual field, spatial-perceptual changes, altered cognitive function, and loss of consciousness. Clinical manifestations depend on factors such as the area(s) of the brain affected, the adequacy of collateral cerebral circulation, and the extensiveness of subsequent cerebral edema.

CVAs are classified according to etiology. The major classifications are ischemic and hemorrhagic. Ischemic CVAs are most frequently the result of a thrombosis (which is usually associated with atherosclerosis) or an embolus. Conditions most often associated with a hemorrhagic CVA are extreme hypertension, cerebral aneurysm, or arteriovenous malformation. Treatment after a CVA is determined by the etiology and the neurological deficits that are present.

This care plan focuses on the adult client hospitalized with signs and symptoms of a CVA. Much of the information is also applicable to clients receiving follow-up care in an extended care or rehabilitation facility or home setting. This care plan focuses on the more common problems that occur as a result of a CVA. The reader should refer to neurological texts for additional information about specific speech, motor, and sensory deficits that can occur.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Have improved cerebral tissue perfusion

2. Have improved or stable neurological function

3. Experience optimal control of urinary elimination

4. Have no signs or symptoms of complications

5. Communicate an awareness of ways to decrease the risk of a recurrent CVA

6. Identify ways to manage sensory and speech impairments and disturbed thought processes

7. Identify ways to improve ability to swallow

8. Identify ways to manage urinary incontinence

9. Demonstrate measures to facilitate the performance of activities of daily living and increase physical mobility

10. Communicate an awareness of signs and symptoms to report to the health care provider and share thoughts and feelings about the effects of the CVA on lifestyle, roles, and self-concept

11. Communicate knowledge of community resources that can assist with home management and adjustment to changes resulting from the CVA

12. Communicate an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider and therapists and medications prescribed.

Collaborative Diagnosis DECREASED INTRACRANIAL ADAPTIVE CAPACITY RELATED TO TRAUMA/NEUROLOGICAL ILLNESS

Definition: Intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of noxious and non-noxious stimuli

CLINICAL MANIFESTATIONS:

Subjective	Objective
Report of headache	Increases in ICP for greater than 5 minutes after stimuli; baseline ICP greater than 10 mm Hg; altered level of consciousness (early); changes in vital signs/cardiac rhythm (late), changes in papillary response, generalized weakness; Positive Babinski sign, seizures

RISK FACTORS:

• Intracranial bleeding

• Cerebral ischemia or infarction

• Brain injury

DESIRED OUTCOMES: Stable ICP as evidenced by improved neurological status

NOC OUTCOMES: Neurological status

NIC INTERVENTIONS: ICP monitoring; neurological monitoring; cerebral edema management

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis RISK FOR INEFFECTIVE AIRWAY CLEARANCE NDx

Definition: Inability to clear secretions from the respiratory tract to maintain patent airway

• Poor cough effort due to fatigue, changes in neuromuscular functioning

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports of shortness of breath (dyspnea)	Dyspnea; orthopnea; diminished breath sounds; adventitious breath sounds (crackles, rhonchi, wheezes); ineffective cough; difficulty vocalizing; restlessness; changes in respiratory rate, rhythm; late sign: cyanosis; decreasing pulse oximetry readings

RISK FACTORS:

Excessive mucus production

Presence of artificial airway

Neuromuscular dysfunction

Infection

Smoking

DESIRED OUTCOMES: The client will maintain a clear, open airway as evidence by:

a. Normal breath sounds

b. Normal rate and depth of respirations

c. Absence of dyspnea

NOC OUTCOMES: Respiratory status: airway patency

NIC INTERVENTIONS: Monitor respirator function; artificial airway management; airway suctioning; chest physiotherapy; cough enhancement

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis RISK FOR ASPIRATION NDx

Definition: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into tracheobronchial passages

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Cough; tachypnea; dyspnea; tachycardia; dull percussion noted over affected lung area; presence of food in aspirate

RISK FACTORS:

• Reduced level of consciousness

• Depressed cough and gag reflexes

• Impaired swallowing in an acute neurological insult

DESIRED OUTCOMES: The client will not aspirate secretions or foods/fluids as evidenced by:

a. Clear breath sounds

b. Resonant percussion over lungs

c. Absence of cough, tachypnea, and dyspnea

NOC OUTCOMES: Aspiration control; respiratory status: ventilation

NIC INTERVENTIONS: Aspiration precautions; respiratory monitoring; swallowing therapy; airway suctioning

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Collaborative Diagnosis INEFFECTIVE TISSUE PERFUSION: CEREBRAL NDx

Definition: Decrease in oxygen resulting in the failure to nourish cerebral tissues at the capillary level

• Embolus cerebral hemorrhage

• Hypotension and/or subsequent spasm

• Compression of cerebral vessels

CLINICAL MANIFESTATIONS:

Subjective	Objective
May not be able to self-report symptoms; only presenting symptoms may be objective.	Altered mental status; changes in motor response; behavioral changes; changes in pupillary reactions; difficulty swallowing

RISK FACTORS:

• Trauma

• Change in circulatory status

DESIRED OUTCOMES: The client will improve cerebral tissue perfusion as evidenced by:

a. Absence of or reduction in dizziness, visual disturbances, and speech impairments

b. Improved mental status

c. Improved sensory and motor function

NOC OUTCOMES: Neurological status; tissue perfusion: cerebral.

NIC INTERVENTIONS: Cerebral edema management; cerebral perfusion pressure promotion; intracranial pressure monitoring

NURSING ASSESSMENT

	RATIONALE
Assess neurological status hourly during acute phase (e.g., dizziness, visual disturbances, aphasia, irritability, restlessness, decreased level of consciousness, paresthesias, weakness, and paralysis).	Provides baseline assessment data and determines signs of decreased tissue perfusions. Changes may be reflective of increased intracranial pressure.
Assess vital signs hourly during the acute phase.	Vitals signs must be maintained at a level that supports adequate oxygenation and perfusion of cerebral tissues.

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis DISTURBED SENSORY PERCEPTION NDx (AUDITORY, KINESTHETIC, VISUAL, TACTILE)

Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reported change in sensory acuity: photosensitive, hyperesthesia, altered sense of taste, inability to sense position of body parts (proprioception)	Measured change in sensory acuity (visual, auditory, tactile); mood swings; exaggerated emotional responses; disorientation to person, place, time; change in behavioral patterns; restlessness; irritability; hallucinations

RISK FACTORS:

• Compression of the nerves

• Edema

DESIRED OUTCOMES: The client will experience a reduction in and/or demonstrate beginning adaptation to disturbed sensory perception as evidenced by:

a. Communication of same

b. Increased participation in activities

NOC OUTCOMES: Sensory function: proprioception; sensory function: vision

NIC INTERVENTIONS: Environmental/sensation management

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis UNILATERAL NEGLECT NDx

Definition: Impairment in sensory and motor response, mental representation, and spatial attention of the body, and the corresponding environment characterized by inattention to one side and overattention to the opposite side; left side neglect is more severe and persistent than right side neglect

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports feeling as though one part of the body does not belong to own self	Inattention to stimuli applied to affected side; lack of awareness of affected side/inattention to safety; failure to use the affected side after being reminded to do so; failure to notice people approaching from the neglected side; marked deviation of the eyes to the non-neglected side to stimuli and activities on that side

DESIRED OUTCOMES: The client will experience a reduction in and/or demonstrate beginning adaptation to unilateral neglect as evidenced by:

a. Awareness of stimuli on affected side

b. Awareness of the affected side of the body

NOC OUTCOMES: Self-care activities of daily living; self-initiated body positioning

NIC INTERVENTIONS: Unilateral neglect management; sensory function: vision; vision compensation behavior

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMPAIRED VERBAL COMMUNICATION NDx

Definition: Decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports difficulty expressing self	Unable to speak dominant language; speaks or verbalizes with difficulty; cannot speak; slurring/stuttering; difficulty forming words and sentences; difficulty in comprehending statements

RISK FACTOR:

• Injury

DESIRED OUTCOME: The client will communicate needs and desires effectively.

NOC OUTCOMES: Communication: receptive; communication: expressive

NIC INTERVENTIONS: Communication enhancement: speech deficit; active listening

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis SELF-CARE DEFICIT NDx (BATHING, FEEDING, DRESSING, TOILETING)

Definition: Inability to perform or complete feeding, bathing/hygiene, dressing and grooming, or toileting activities for oneself

Related to:

• Impaired physical mobility

• Visual and spatial-perceptual impairments

• Apraxia

• Unilateral neglect

• Disturbed thought processes

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Inability to prepare food, handle or use containers and/or utensils; inability to handle a glass or cup; inability to bathe or access the bathtub or shower; inability to dress self, use button closures; inability to get to the toilet or manipulate clothing; inability to provide appropriate personal hygiene

RISK FACTORS:

• Weakness

• Loss of neuromuscular activity

• Bed rest

DESIRED OUTCOME: The client will perform self-care activities within cognitive and physical limitations.

NOC OUTCOMES: Self-care: activities of daily living

NIC INTERVENTIONS: Self-care assistance: activities of daily living; exercise therapy; muscle control

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Collaborative/Nursing Diagnosis ACUTE AND CHRONIC CONFUSION NDx

Definition:

Acute: Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception

Chronic: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes; manifested by disturbances of memory, orientation, or behavior

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Inaccurate interpretation of environment and time; memory loss; altered mood states (e.g., lability, hostility, irritability, inappropriate affect); inability to make decisions or problem solve; changes in attention span; disorientation; inappropriate social behavior

RISK FACTOR:

• Cerebral edema

DESIRED OUTCOMES: The client will experience less confusion as evidence by:

a. Improved attention span, memory, and problem-solving abilities

b. Improved level of orientation

c. Reduction in instances of inappropriate responses

NOC OUTCOMES: Information processing; neurological status: consciousness; cognitive ability; disoriented thought self-control; memory; mood equilibrium

NIC INTERVENTIONS: Reality orientation; cognitive stimulation; dementia management; presence; behavior management

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT NDx; OR INEFFECTIVE HEALTH MAINTENANCE^* NDx

Definition: Absence or deficiency of cognitive information related to specific topic (lack of specific information necessary for clients/significant others) to make informed choices regarding condition/treatment/lifestyle changes; pattern of regulating and integrating into family processes a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals; inability to identify, manage, and/or seek out help to manage health

CLINICAL MANIFESTATION:

Subjective	Objective
Requests information; client statements reflect misunderstanding	Inadequate follow through of instruction; inappropriate or exaggerated behaviors

RISK FACTOR:

• Cognitive limitations or unfamiliarity of situation

NOC OUTCOMES: Knowledge: disease process; knowledge: treatment regimen; knowledge: health resources

NIC INTERVENTIONS: Teaching: individual; teaching: disease process; teaching: psychomotor skills; teaching: prescribed activity

NURSING ASSESSMENT

	RATIONALE
Assess for stroke-related factors that may impede the learning process.	Client may not be emotionally or physically able to learn.
Assess client/family understanding of disease process.	The nurse’s understanding of the client’s and significant other’s knowledge based aids in formulating an educational plan.

THERAPEUTIC INTERVENTIONS

ADDITIONAL NURSING DIAGNOSES

IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS NDx

GRIEVING NDx

IMPAIRED SWALLOWING NDx

IMPAIRED PHYSICAL MOBILITY NDx

• Loss of muscle tone during period of flaccidity of affected extremities (flaccid paralysis is usually present during the first few days after a CVA)

• Hypertonia of affected extremities (as muscle tone returns after period of flaccidity, it often progresses to spasticity within about 6-8 weeks)

• Reluctance to move associated with fear of injuring self (occurs mainly with ischemia of the dominant hemisphere)

• Loss of muscle mass, tone, and strength associated with prolonged disuse

IMPAIRED URINARY ELIMINATION: INCONTINENCE NDx

• Decreased ability to control urination associated with decreased level of consciousness or inability to recognize sensation of bladder fullness

• Inability to get to bedside commode or bathroom in a timely manner associated with:

• Delay in obtaining assistance resulting from inability to communicate the urge to urinate

• Impaired physical mobility

DISTURBED SELF-CONCEPT NDx

• Lifestyle and role changes associated with motor and spatial-perceptual impairments and disturbed thought processes

• Impaired verbal communication

• Loss of self-control (e.g., automatic speech, emotional lability, inappropriate behavior) or exaggerated emotional responses

• Urinary incontinence

• Dependence on others to meet basic needs

INEFFECTIVE COPING NDx

• Decreased ability to communicate verbally

• Changes in motor and sensory function, thought processes, and future lifestyle and roles

• Need for lengthy rehabilitation

INTERRUPTED FAMILY PROCESSES NDx

• Disturbed thought processes

• Need for lengthy rehabilitation

CRANIOCEREBRAL TRAUMA/CRANIOTOMY

The leading causes of craniocerebral trauma (head injury, traumatic brain injury) are motor vehicle accidents, falls, sports/recreational injuries, and assaults. Examples of skull and brain injury that can occur include skull fracture; dural tear; cerebral contusion, concussion, and laceration; diffuse axonal injury (DAI); brainstem damage; and intracranial hemorrhage. Brain damage can occur during the initial injury and as a result of subsequent cerebral damage resulting from factors such as cerebral hematoma, infection, and edema; seizure activity; and/or obstruction of the flow of cerebrospinal fluid (CSF).