NURSING INTERVENTION STROKE

Nursing Interventions for Stroke Patients

Overview of Nursing Interventions

  • When caring for a patient who has received Tissue Plasminogen Activator (TPA), a critical medication for stroke treatment, nurses must perform several interventions to ensure patient safety and recovery.

  • Bleeding Monitoring:

    • Continuous monitoring for any signs of bleeding due to the nature of TPA, which increases bleeding risk.

Vital Signs Monitoring

  • Blood Pressure Management:

    • Administer antihypertensive medications if necessary to keep blood pressure within recommended parameters.

  • Other Vital Signs:

    • Continuously monitor heart rate and respiratory rate.

    • Look for signs of increased intracranial pressure, which may manifest as:

    • Elevated blood pressure

    • Decrease in heart rate and respirations

    • Symptoms such as nausea, vomiting, altered level of consciousness

    • Unequal pupil response

Airway and Aspiration Risk

  • Monitor the airway closely due to potential swallowing difficulties post-stroke.

    • Oral secretions may accumulate, leading to aspiration risk.

    • Ensure suction equipment is readily available.

Cranial Nerve Assessment

  • Assess cranial nerves using the following methods:

    • Check pupils for reaction.

    • Test the ability to swallow and the gag reflex with cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve)

Assessing Bladder and Bowel Function

  • Monitor for urinary incontinence or retention.

    • Offer bedpans or bedside commodes.

    • Utilize a Foley catheter if necessary.

  • Assess for urinary retention using a bladder scanner.

    • Procedure:

    • Apply ultrasound jelly to the scanner.

    • Analyze the bladder for urine presence and volume.

Skin and Limb Integrity Maintenance

  • Reposition the patient every two hours to prevent pressure ulcers, especially for those unable to move one side of the body.

  • Perform passive range of motion exercises for extremities to reduce stiffness and improve mobility.

Neglect Syndrome and Hemianopsia

  • Neglect Syndrome:

    • Often seen in patients with a right-sided brain injury leading to left side neglect.

    • Patients may ignore or fail to use the affected side.

    • Interventions to help:

    • Remind patients to consciously engage with the neglected side.

    • Encourage environmental scanning to prevent injuries.

  • Hemianopsia:

    • Defined as loss of half the visual field, potentially leading to self-injury.

    • Assessment involves:

    • Showing the patient objects and asking them to describe what they see.

    • Training patients to scan their environment to compensate for visual deficits.

Diet and Swallowing Considerations

  • Patients may have swallowing difficulties (dysphagia), necessitating a swallow study by a speech-language pathologist.

  • Dietary recommendations may include:

    • Thickened liquids (e.g. honey-thick, nectar-thick) for safe swallowing.

    • Mechanical soft diet for easier consumption.

  • Assistance with Eating:

    • Nurses must supervise patients to prevent pouching of food in the cheeks, particularly on the affected side, to avoid aspiration.

    • Teaching strategies:

    • Chin tuck during swallowing.

Communication Challenges

  • Patients may experience aphasia, which affects their ability to communicate effectively but does not mean they have a cognitive deficit.

  • Types of Aphasia:

    • Receptive Aphasia: Inability to comprehend spoken language.

    • Communication Techniques:

    • Use short, clear phrases and limit information overload.

    • Incorporate gestures and visual aids to facilitate understanding.

    • Employs a collaborative approach, including the patient’s family and multidisciplinary teams (e.g., speech therapy, occupational therapy).

    • Be patient and repeat words

    • Expressive aphasia:

    • Be patient and let them speak

    • Ask one question at a time

    • Be direct and ask questions with simple option or response

    • Use communication response board

Family Involvement in Care

  • Engage family members in the patient's care to facilitate understanding and preparation for post-discharge support.

  • Include family in treatment plans and patient education regarding ongoing care after hospital discharge.