Stroke is a functional abnormality of the CNS that occurs when the blood supply to the brain is disrupted. To understand the nursing care plan for stroke, please read this article completely.
Stroke is divided into types, Ischemic Stroke & hemorrhagic Stroke.
Ischemic stroke represents 87% of all strokes. Nurses play a pivotal role in all phases of care of stroke patients. So they need to understand 2 phases of stroke care. Phase 1 being the emergency phase, which includes the prehospital setting and the emergency department (ED). And phase 2 being the acute-care phase, which includes critical care units, intermediate care units, stroke units, and general medical units.
Emergency phase (Phase 1)
The emergency or hyperacute phase encompasses the first 3 to 24 hours after onset of stroke. The key elements of prehospital care are stabilization of the airway, breathing, and circulation. Identification of signs and symptoms of a stroke. Establishment or verification of the last known well time, provision of supplemental oxygen to patients with hypoxemia, checking the blood glucose level, avoidance of the administration of glucose-containing fluids (unless the patient is hypoglycemic), rapid initiation of transport (load and go) and delivery of patients to receiving centers capable of rapidly caring for acute stroke.
In Emergency department:
The triage nurse should use specialized checklists, protocols, and thus the other tools to identify stroke patients. The nurse uses these procedures and protocols that define who contacts the acute stroke team and therefore appropriate neurological consultant once the stroke is confirmed. Emergency nurses understand that time is critical and are trained in rapid assessment and treatment of stroke patients. Studies have shown that the sooner thrombolytic therapy is started, the greater the benefit. It is critical that all emergency nurses and other emergency professional staff know that the benchmark treatment time for AIS with intravenous rtPA is within 60 minutes of arrival in the ED. Patients with AIS are at risk of hypoxemia and oxygen desaturation. Hypoxic patients will benefit from supplemental oxygen.
The positioning of the head of the bed must be individualized for each patient. The beds should be elevated at least 30° if the patient is at risk of aspiration or airway obstruction due to dysphagia. Otherwise, the head-flat position maximized blood flow to the brain. When significant hemiparesis is present, positioning on the paretic side may be more desirable to allow the patient to communicate and to prevent aspiration. However, the placement of lines and tubes should be rapid and should not delay the administration of rtPA by more than a few minutes.
Acute Phase (Phase 2)
Bleeding assessment after administration of rtPA is the responsibility of the clinical nurse, who monitors the patient for major and minor bleeding complications in the first 24 to 36 hours after administration of rtPA. ICH is the major bleeding complication associated with thrombolytic therapy.
Blood pressure is a critical vital sign in the AIS patient and thus It is not uncommon to see variations in blood pressure after AIS. Rapid lowering of blood pressure may induce worsening of neurological symptoms, therefore, inducing lowered perfusion pressures to the area of ischemia.
Fever appears to exacerbate the ischemic injury to neurons and is associated with increased morbidity and mortality, particularly in acute stroke. Even an increase of 1°F is a predictor of poorer patient outcomes. Cardiac monitoring is recommended for all ischemic stroke patients. Cardiac arrhythmias (ventricular ectopy, tachycardia, and heart blocks) and sudden cardiac death can occur.
The monitoring of oxygen saturation will reduce the risk of neurological deterioration related to hypoxemia. Supplemental oxygen at 2 to 4 L/min is recommended for an oxygen saturation of 92%. Both hyperglycemia and hypoglycemia cause adverse effects and thus they should be corrected promptly. Seizures are a possibly life-threatening complication of large cortical strokes. Therefore, a nurse must educate the patient and family about the anticonvulsant drug (if required).
Improving mobility and preventing deformities position thus to prevent contractures. Use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies. Apply a splint at night to prevent the ﬂexion of the affected extremity. Prevent the adduction of the affected shoulder with a pillow placed in the axilla. Elevate affected arm to prevent edema and ﬁbrosis. Change position every 2 hours; place the patient in a prone position for 15 to 30 minutes several times a day.
Establishing an Exercise Program
Provide a full range of motion four or ﬁve times a day to maintain joint mobility. Regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. If tightness occurs in any area, perform a range of motion exercises more frequently. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.because of the nursing care plan for stroke
Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (eg, shortness of breath, chest pain, cyanosis, and increased pulse rate). Supervise and support the patient during exercises; plan frequent short periods of exercise, not longer periods; encourage patients to exercise unaffected side at intervals throughout the day. because of the nursing care plan for stroke
Preventing Shoulder Pain Never
Lift the patient by the ﬂaccid shoulder or pull on the affected arm or shoulder. A range of motion exercises are beneﬁcial but avoid over strenuous arm movements. Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as indicated.
Enhancing Self Care Encourage
Personal hygiene activities as soon as the patient can sit up. Help the patient to set realistic goals; add a new task daily. As a ﬁrst step, encourage the patient to carry out all self-care activities on the unaffected side. And therefore make sure the patient does not neglect the affected side; provide assistive devices as indicated. because of the nursing care plan for stroke
Assisting with Nutrition Observe
Patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, and therefore, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. Nursing Care Plan For Stroke because
Attaining Bowel and Bladder Control
Perform intermittent sterile catheterization during the period of loss of sphincter control. Therefore analyze voiding patterns and offer a urinal or bedpan on the patient’s voiding schedule. Nursing Care Plan For Stroke because
Improving Thought Processes
It reinforces a structured training program using cognitive-perceptual retraining, visual imagery, reality orientation, and thus cueing procedures to compensate for losses. Nursing Care Plan For Stroke because
WHAT THIS SHOULD LEAD TO
The patient achieves improved mobility. Has no complaints of pain. Achieves self-care; performs hygiene care; uses adaptive equipment. Demonstrates techniques to compensate for an altered sensory reception, therefore turning the head to see people or objects. Demonstrates safe swallowing. Achieves normal bowel and bladder elimination. because of the nursing care plan for stroke
Participates in the cognitive improvement program. Demonstrates improved communication. Maintains intact skin without breakdown. Family members demonstrate a positive attitude and coping mechanisms. Develops alternative approaches to sexual expression. because of the Nursing Care Plan For Stroke Because
Cerebral function improved, neurological deficits resolving/stabilized. Complications prevented or minimized. Coping with the situation in a positive manner, planning for the future. Disease process/prognosis and therapeutic regimen understood. Plan in place to meet needs after discharge. Nursing Care Plan For Stroke. because. therefore.
because of the nursing care plan for stroke. because of the nursing care plan for stroke/
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