Rationale: May be used to improve cerebral blood flow and prevent further clotting when embolism and/or thrombosis is the problem. Achieves selfcare; performs hygiene care; uses adaptive equipment. Rationale: Rehabilitation helps to relearn skills that are lost when part of the brain is damaged. Develops alternative approaches to sexual expression. Hemiplegia ------->paralysis one side. Fall prevention measures (non-skid socks, bed in the lowest locked position, call bell within reach, and so forth), Injury prevention; the patient will most likely not be able to ambulate as well as they could before the stroke and will require assistance, Extremities that are now paralyzed are at risk for becoming contracted; ensure pillow supports are in place, as well as rolled towels in hands and adaptive devices, Maximizes time with the patient so they can rest when care is not being provided, Monitor vital signs appropriately; know BP limits. Rationale: Suggests rejection of body part and negative feelings about body image and abilities, indicating need for intervention and emotional support. Assess abilities and level of deficit (0–4 scale) for performing ADLs. Table 10. Any patient with neurologic deficits need a careful history and complete physical and neurologic examination. Prevention of DVT is one of the core performance measures for primary stroke center certification, and initiation of prevention has become a quality indicator in several populations.241,242 Safe ambulation should be started as soon after stroke as possible. The degree of neurologic damage that occurs with an ischemic stroke depends on the: Size of the area of inadequate perfusion. For cerebellar infarcts and hemorrhages in which hydrocephalus and a generalized increase in ICP are an issue, an ICP catheter is usually not inserted. Table 6 summarizes nursing care associated with thrombolysis and nonthrombolysis treatment of patients with acute cerebral ischemia on the basis of the original NIH-NINDS study protocol and AHA/ASA guidelines.2,29,83–86, Table 6. Nurses may work as EMTs and paramedics, radio providers of online medical control to EMS personnel from base stations, and educators who teach EMS personnel about stroke and the care of stroke patients. Wijdicks240 found a sudden death rate of 50% in patients with pulmonary embolism that occurred between 3 and 120 days after the initial stroke event. And then the last one, I think we’ll look at that communication issue, especially if you have a patient with Aphasia or dysphasia. In summary, the present scientific statement describes nursing’s vital role in the first 2 phases of stroke, the emergency or hyperacute phase and the acute phase. Only 27% of patients attending the screening had implemented an intervention to decrease stroke risk.305 Similar studies showed that ≈50% of those attending a stroke screening made at least 1 behavioral change to reduce stroke risk and that community education improved the participant’s knowledge of stroke warning signs and symptoms.306–308. So let’s talk communication, again, dysphasia or aphasia, might even have decreased LOC, especially if it was a severe stroke. Prepare for surgery, as appropriate: endarterectomy, microvascular bypass, cerebral angioplasty. Rationale: Assists patient to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality. Among stroke neurologists and neuroscience nurses, it is the most widely used stroke deficit scale. Rationale: May indicate onset of depression (common after effect of stroke), which may require further evaluation and intervention. This would be unstable at best; at worse, impossible. Encourage everyone to approach the patient with a supportive and optimistic attitude, focusing on abilities that remain; explain to the family that emotional lability usually improves with time. Remind patient with hemianopsia of the other side of the body; place extremities so that patient can see them. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position. 3. Treatment of severe hypoglycemia should be instituted promptly by EMS personnel. Intermittent catheterization is recommended if postvoid residual urine volume is >100 mL.235. Holding the cane in her left hand, Ms. Kelly. Direct and indirect costs for stroke cost $65.5 billion in 2008. The simplest but most valuable thing the nurse can do to monitor nutrition is to monitor the patient’s weight and weight change over time and monitor the patient’s dietary intake.263–265. Stroke patients who need long-term nursing home care suffer from problems in several domains. One study showed that financial outcomes were significantly improved when APNs functioned as outcome managers and collaborated with the multidisciplinary team to care for AIS patients.286 Patients had shorter lengths of stay, lower rates of UTI and skin breakdown, and less time until mobilization. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended. Stroke Daily Progress Note Name: Date/Time: / / @ Allergies: NKDA See list Problem List: Ischemic CVA ICH SDH SAH DM COPD DVT CAD HTN Obesity TIA Dyslipidemia CHF Other: tPa patient… To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis on the affected side. A: Allergic reaction is not a side effect of tPA. Teach patients about the “act FAST” Campaign. Keep training periods for ambulation short and frequent. Maintains intact skin without breakdown. Use of transcranial Doppler ultrasound to enhance the thrombolytic activity of intravenous rtPA is being evaluated in phase II clinical trials.112 These device catheters have been evaluated in safety and technical efficacy trials. Lack of blood flow for greater than 10 minutes can cause irreversible damage. Change in level of consciousness or responsiveness. Rationale: Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. Postseizure patients may present with unilateral weakness (Todd’s paralysis), and strokelike deterioration can occur in a patient with a brain neoplasm. ICP increases as a result of cerebral edema, and monitoring for increased ICP should be part of the ongoing assessment of AIS patients. Rationale: Continued use (after change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion. When oral intake is authorized, the nurse should follow the speech language pathologist’s recommendations,257 which include improving the patient’s ability to concentrate while eating with minimal distractions. Another study found that improved patient outcomes were highly dependent on support systems, including family support and an organized systems approach to meeting the discharge needs of the patient and family.282. Rationale: Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance and positioning and appropriateness of movement, which interferes with ambulation, increasing risk of trauma. The most widely available stroke teaching tool for this purpose21 is chapter 9 of the AHA stroke module.44,51 Educational videos and other tools are also available for the EMS audience.52, Before beginning an EMS stroke education program, the nurse educator should verify local policies and regulations governing acceptable practice for paramedics and EMTs in that region or state.