Collaborative Care

Acute Care

Assessment findings
Altered level of consciousness Weakness, numbness, or paralysis Speech or visual disturbances Severe headache or heart rate Respiratory distress Unequal pupils

Collaborative Care
Acute Care

Interventions Initial
Ensure patient airway Remove dentures Perform pulse oximetry Maintain adequate oxygenation IV access with normal saline Maintain BP according to guidelines

Collaborative Care
Acute Care

Interventions Initial
Remove clothing Obtain CT scan immediately Perform baseline laboratory tests Position head midline Elevate head of bed 30 degrees if no symptoms of shock or injury

Collaborative Care
Acute Care

Interventions Ongoing
Monitor vital signs and neurologic status

Level of consciousness Motor and sensory function Pupil size and reactivity O2 saturation Cardiac rhythm

Collaborative Care
Acute Care

Recombinant tissue plasminogen activator (tPA) is used to

Reestablish blood flow through a blocked artery to prevent cell death in patients with acute onset of ischemic stroke symptoms

Collaborative Care
Acute Care

Thrombolytic therapy given within 3 hours of the onset of symptoms

disability But at the expense of in deaths within the first 7 to 10 days and in intracranial hemorrhage

Collaborative Care
Acute Care

Surgical interventions for stroke include immediate evacuation of

Aneurysm-induced hematomas Cerebellar hematomas (>3 cm)

Collaborative Care
Rehabilitation Care

After the stroke has stabilized for 1224 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning Patient may be transferred to a rehabilitation unit

Nursing Management
Nursing Implementation

Respiratory System

Management of the respiratory system is a nursing priority Risk for aspiration pneumonia Risks for airway obstruction May require endotracheal intubation and mechanical ventilation

Nursing Management
Nursing Implementation

Neurologic System

Monitor closely to detect changes suggesting

Extension of the stroke ICP Vasospasm Recovery from stroke symptoms

Nursing Management
Nursing Implementation

Cardiovascular System

Monitoring vital signs frequently Monitoring cardiac rhythms Calculating intake and output, noting imbalances Regulating IV infusions

Nursing Management
Nursing Implementation

Cardiovascular System

Adjusting fluid intake to the individual needs of the patient Monitoring lung sounds for crackles and rhonchi (pulmonary congestion) Monitoring heart sounds for murmurs or for S3 or S4 heart sounds

Nursing Management
Nursing Implementation

Musculoskeletal System

Trochanter roll at hip to prevent external rotation Hand cones to prevent hand contractures Arm supports with slings and lap boards to prevent shoulder displacement

Nursing Management
Nursing Implementation

Integumentary System

Skin of the patient is susceptible to breakdown related to loss of sensation, circulation, and immobility Compounded by patient age, poor nutrition, dehydration, edema, and incontinence

Nursing Management
Nursing Implementation

Integumentary System

Pressure relief by position changes, special mattresses, or wheelchair cushions Good skin hygiene Emollients applied to dry skin

Nursing Management
Nursing Implementation

Integumentary System

Early mobility Position patient on the weak or paralyzed side for only 30 minutes

Nursing Management
Nursing Implementation

Gastrointestinal System

After careful assessment of swallowing, chewing, gag reflex, and pocketing, oral feedings can be initiated Feedings must be followed by scrupulous oral hygiene

Nursing Management
Nursing Implementation

Communication

Nurses role in meeting psychologic needs of the patient is primarily supportive Patient is assessed both for the ability to speak and the ability to understand Speak slowly and calmly, using simple words or sentences

Nursing Management
Nursing Implementation

Sensory-Perceptual Alterations

Blindness in the same half of each visual field is a common problem after stroke Other visual problems may include diplopia (double vision), loss of the corneal reflex, and ptosis (drooping eyelid)

Nursing Management
Nursing Implementation

Ambulatory and Home Care

The rehabilitation nurse assesses the patient and family with

Rehabilitation potential of the patient Physical status of all body systems Presence of complications caused by the stroke or other chronic conditions Cognitive status of the patient

Nursing Management
Nursing Implementation

Ambulatory and Home Care

The patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility

Nursing Management
Nursing Implementation

Ambulatory and Home Care

Nurses have an excellent opportunity to prepare the patient and family for discharge through

Education Demonstration Practice Evaluation of self-care skills