A 61-year-old client recently had left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention?
a. Encouraging an even gait when walking in place
b. Assessing the extremities for unilateral swelling and muscle atrophy
c. Encouraging holding the breath frequently to hyperinflate the lungs
d. Teaching the use of a two-point crutch technique for ambulation
B
Because edema moves to dependent body regions, assessment of the immobilized client should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis.
The client who has suffered a cerebrovascular accident with left-sided paralysis may not be ca-pable of an even gait.
Having the client hold his or her breath frequently is not an appropriate nursing intervention. To prevent stasis of pulmonary secretions, the client's position should be changed every two hours, and fluids should be increased to 2000 mL, if not contraindicated. The client should deep breathe and cough every one to two hours to promote chest expansion.
Two-point crutch technique would not be appropriate for the client with left-sided paralysis. The client would most likely ambulate safely with a walker or a cane. If crutches are used, the client should use a three-point support.
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