Section 8: Acute Stroke Nursing Care

NUR 433: Adult Health II; MCUSON; Mrs. Cooper

Nursing care in the first days protects cerebral perfusion and prevents aspiration, VTE and falls. Many patients get worse in the first ___ - ___ hours, so frequent neuro checks continue.

24-48

Health history: risk factors; prior stroke or TIA; all prescribed, OTC and illicit drugs (especially anticoagulants and oral contraceptives); smoking; and the exact _____

last known normal (LKN)

Focused neuro exam (be able to describe each step):

1. LOC: alertness, orientation, answers questions, follows commands. Early LOC changes may mean ↑ _____

ICP

Focused neuro exam (be able to describe each step):

2. Communication: _____ type and _____. You can assess LOC and speech in the same conversation

aphasia; dysarthria

Focused neuro exam (be able to describe each step):

3. Cranial nerves: Facial palsy (CN ___): smile, show teeth, raise eyebrows. CN ___, ___, ___: pupils equal and reactive; eyes follow your finger (gaze deviation?). _____ fields: finger counting or visual threat. Neglect: does the patient ignore one _____?

VII; III, IV, VI; visual; side

Focused neuro exam (be able to describe each step):

4. Motor: arms held up for ___ seconds, legs for ___ seconds; equal grips. Note drift, flaccidity, spasticity

10; 5

Focused neuro exam (be able to describe each step):

4. Coordination: finger–nose–finger and heel–shin for limb _____

ataxia

Focused neuro exam (be able to describe each step):

6. Sensory: response to _____ (grimace or withdrawal), compared side to side

pinprick

Focused neuro exam (be able to describe each step):

7. Reflexes: gag, corneal and pupillary reflexes test _____ function

brainstem

assessment: 1. Maintain cerebral perfusion and airway

• Assess airway and lungs (crackles, wheezes, distress). _____ only as needed and briefly

suction

assessment: 1. maintain cerebral perfusion and airway

• Give O₂ as ordered to keep SpO₂ above ___

94%

assessment: 1. maintain cerebral perfusion and airway

• ___-___ position if the patient is seizing or can’t protect the airway

side-lying

assessment: 1. maintain cerebral perfusion and airway

• Neuro checks: commonly ___ × ___, then ___ once stable (more often after thrombolytics, per protocol)

q24 × 4; q4h

assessment: 1. maintain cerebral perfusion and airway

• Report _____, drowsiness, confusion or new weakness

restlessness

assessment: 1. maintain cerebral perfusion and airway

• Monitor pupils, strength, gag reflex, headache, cardiac rhythm (___), temperature (fever worsens injury; hypothalamic involvement) and I&O (diabetes insipidus with pituitary involvement)

a-fib

assessment: 1. maintain cerebral perfusion and airway

• Keep _____ in a normal range and treat fever

glucose

assessment: 2. prevent aspiration (priority safety issue)

• Keep NPO, including oral meds and aspirin, until the patient passes a _____ screen. Document the screen. Speech therapy evaluates within 24 hours

swallow

assessment: 2. prevent aspiration (priority safety issue)

• Check the _____ reflex before any feeding

gag

assessment: 2. prevent aspiration (priority safety issue)

• Sit the patient upright (___ ___, ___) for meals and 30 minutes afterward

high Fowler’s, 90 degrees

assessment: 2. prevent aspiration (priority safety issue)

• _____ ____: keep the head flexed slightly forward to swallow. Don’t tilt the head back; that opens the airway to aspiration

chin tuck

assessment: 2. prevent aspiration (priority safety issue)

• Place food on the _____ side of the mouth. Small bites; swallow twice

unaffected

assessment: 2. prevent aspiration (priority safety issue)

• Use the diet and liquid consistency ordered by speech therapy (often _____ liquids)

thickened

assessment: 2. prevent aspiration (priority safety issue)

• Provide ___:___ supervision, minimize distractions, and keep suction at the bedside

1:1

assessment: 2. prevent aspiration (priority safety issue)

• Check for _____ food and give mouth care after meals

pocketed

assessment: 2. prevent aspiration (priority safety issue)

• Monitor lung sounds and temperature for aspiration _____

pneumonia

assessment: 3. prevent complications of immobility

• Active ROM on the unaffected side; passive ROM on the affected side at least ___ to prevent contractures

q4h

assessment: 3. prevent complications of immobility

• Turn ___; support the affected limbs and pad bony prominences

q2h

assessment: 3. prevent complications of immobility

• _____ positioning only with a provider order

prone

assessment: 3. prevent complications of immobility

• _____ prophylaxis: SCDs or stockings per order, early mobility, and assessment for DVT (warmth, redness, swelling, pain)

VTE

assessment: 3. prevent complications of immobility

• _____ precautions, especially for right-hemisphere and cerebellar strokes

fall

assessment: 4. communicate with the aphasic patient

• Face the patient, speak slowly, and use short, simple sentences with one instruction at a time. Don’t _____; aphasia isn’t hearing loss

shout

assessment: 4. communicate with the aphasic patient

• Allow time to _____; be honest when you don’t understand

respond

assessment: 4. communicate with the aphasic patient

• Use ___/___ questions, gestures, picture boards or a writing tablet to assess pain and needs

yes/no