Nursing Care of Stroke Patient
MedSurg
Neurological disorders
With Rhonda Lawes
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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SBAR Report from ICU
S
Situation: I am (name), (x) nurse on ward x). I am calling about (patient X).
I am calling because I am concerned that
blood pressure is low/high,
pulse is XX, temperature is XX, Early Warning Score is XX)
B
Background: Patient (X) was admitted on (XX date) with (e.g., MI/chest infection).
They have had (X operation/procedure/investigation). Patient
changed in the last (XX mins). Their last set of obs were (XX). Patient
., alert/drowsy/confused, pain free).
A
R
Assessment: I think the problem is (XXX), and
., given O2/analgesia,
stopped the infusion) or I am not sure what the problem is but patient (X) is
deteriorating or I
Recommendation: I need you
to see the patient in the next (XX mins)
AND: Is there anything I need to do in the mean time? (e.g., stop the fluid/repeat
the obs)
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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SBAR Report from ICU
S
Situation
B
Background
A
Assessment
R
Recommendation
•
Practice receiving an abbreviated report
from the ICU nurse and writing down the
information that you feel is important.
•
Write your notes about report in your
downloadable notes.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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HCP Initial Orders
•
Admit patient to telemetry med/surg unit
for telemetry monitoring.
•
Give the patient oxygen at 2 liters per
nasal cannula.
•
•
•
Monitor blood pressure every 4 hours for
the first 24 hours and then every 8 hours.
Notify HCP if blood pressure is above
180/105 mm Hg.
•
Give the patient normal saline at
75 mL/hour until patient is cleared by
speech therapy to take oral fluids.
•
Discontinue saline if patient is able to
drink fluids.
Monitor continuous oxygen saturation
and wean oxygen to keep saturation
> 94%.
He should get physical therapy, speech
therapy, occupational therapy, and
registered dietician consult.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Goals for Acute Stroke Treatment
In the telemetry/medical surgical unit:
•
Maintain medical stability of patient
(ABCs).
•
Minimize possible complications from
stroke.
•
Monitor neurological status,
cardiovascular status, cardiac rhythm,
and vital signs.
•
Facilitate optimum functioning for the
patient after stroke.
•
Continue collaborative interdisciplinary
evaluation and discharge planning
including physical therapy, speech
therapy, occupational therapy, social
work, and registered dietician.
•
Recognize any signs of deteriorating
condition in level of consciousness
(LOC) and mentation early.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Immediate Nursing Priorities
Safe transfer
Transport Mr. Johnson from the ICU gurney and monitors to
the med surg/telemetry monitor.
ABC
Assess airway, breathing and circulation including vital signs (TPR
and pulse oximetry, cardiac rhythm, and blood pressure).
Continuity of care
Do additional bedside report with ICU nurse and verify neuro
assessment, oxygen, any IV rates etc. and completed physician
orders.
Assessment
Do an admission assessment head to toe, review NIHSS and
review HCP orders.
Prioritize care
Prioritize care for the shift and continue interdisciplinary
discharge planning.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Immediate Nursing Priorities
Vitals
94/min
Heart rate: ______________________
37.2°C (98.9°F)
Temperature:_____________________
Sinus rhythm with PACs
Cardiac rhythm:__________________
FSBS:___________________________
150/88 mm Hg
Blood pressure:___________________
22/min
Respiratory rate:__________________
Onset of symptoms:________________
96%
Pulse ox:________________________
________________________________
2L NC
O2:_____________________________
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Nursing Priorities by System
Neurologic
GI
Cardiovascular
Renal/urinary
Respiratory
Skin
Musculoskeletal/
mobility
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Neurologic Interventions
Goal: Early identification of neurological deterioration
•
Repeat NIHSS assessment as indicated.
•
Monitor for extension of stroke.
•
Change in level of consciousness (LOC) indicates elevated ICP.
•
Regularly assess mental status, pupillary responses, extremity
movement and strength.
•
Use every interaction as an opportunity for informal patient assessment.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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NIH Stroke Scale
The NIHSS is a multiple item neurologic examination stroke
scale used to evaluate the effect of acute cerebral infarction.
Pause the video. Google Stroke Scale
Calculator. Practice scoring Mr. Johnson
from what you know.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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NIH Stroke Scale
The NIHSS is a multiple item neurologic examination stroke
scale used to evaluate the effect of acute cerebral infarction on:
1
Level of consciousness
:____
6
Motor strength
:____
2
Language
:____
7
Ataxia
:____
3
Neglect
:____
8
Dysarthria
:____
4
Visual-field loss
:____
9
Sensory loss
:____
5
Extraocular movement
:____
Total Score:
:____
Source: https://www.stroke.nih.gov/, https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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NIH Stroke Scale
•
The NIHSS takes less than
10 minutes to complete by a
certified nurse or physician.
•
Utilized at intervals: baseline,
2 hours post treatment, 24 hours
post onset of symptoms,
7 10 days, 3 months, etc.
https://www.stroke.nih.gov
https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Neurologic Interventions
Goal: Assess and improve cognitive and functional abilities
•
conversation.
•
Communication difficulties can cause anxiety and sensory overwhelm
for stroke patients.
•
Use calm and slow, but natural speech.
•
Frequent shorter conversations may be most beneficial.
•
Maintain eye contact and smile.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Neurologic Interventions
Goal: Assess and improve cognitive and functional abilities
•
Intentionally choose to not appear rushed or impatient.
•
Reassure patient without patronizing.
•
Simplify sentences without patronizing.
•
Give patient time to process and respond.
•
Collaborate with speech therapy to create a plan to support
communication and possible communication aids (picture boards, etc.).
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Neurologic Interventions
Goal: Assess and improve cognitive and functional abilities
Sensory-perceptual alterations: Alterations will differ depending on which
hemisphere(s) are involved.
•
Vision problems could include: diplopia (double vision)
•
Loss of the corneal reflex
•
Ptosis (drooping eyelid)
•
Homonymous hemianopsia
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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The Brain and Vision
L
The left half of the brain processes visual
information from both eyes about the right
side of the visual world.
Walkerssk, CC0
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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R
The Brain and Vision
L
The left half of the brain processes visual
information from both eyes about the right
side of the visual world.
R
The right half of the brain processes visual
information from both eyes about the left
side of the visual world.
Walkerssk, CC0
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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The Brain and Vision
L
R
With homonymous hemianopsia a person can only see
the right or left side of their visual world.
Walkerssk, CC0
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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What are the symptoms of homonymous hemianopsia?
•
Bumping into or failing to notice things on the side of
the hemianopsia this can make such everyday tasks
as crossing the street or driving a car unsafe
•
Missing parts of words or parts of an eye chart on the
side of the hemianopsia when reading
•
Not noticing objects on a desk or table, or even food
on a plate to the side of the hemianopsia
•
Frustration with reading because it is difficult for the
eyes to pick up the beginning of the next line
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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What are the symptoms of homonymous hemianopsia?
•
Tendency to turn the head or body away from the side
of the hemianopsia
•
Drifting in a direction away from the hemianopsia when
walking
•
Visual hallucinations that appear in the form of lights,
shapes, or geometric figures or as the image of a
recognizable object. Sometimes a movement noted on
the normal side of vision is believed to be also seen at
the same time on the side of the visual loss
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Additional Teaching Notes
Mr. Johnson
How to help:
•
When moving through the environment, learn to direct
the eyes toward the good visual field.
•
When walking into a new environment, pause and
move your head from one side to another. Observe
where objects and people are located. Think about
painting a picture of what you see in your brain.
Practicing this, particularly in the 6 months after vision
loss, can help train your brain to do this automatically.
•
When walking, let a partner walk on the blind side and
provide his or her arm for guidance.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Additional Teaching Notes
Mr. Johnson
How to help:
•
When in group situations, situate people in the good
field of vision as much as possible.
•
When in a theater, sit far over to the blind side so that
the action takes place in the normal visual field.
•
Play real-life (not computer-based) card games and do
crossword puzzles to regain coordination between
vision and touch.
•
Do word search or picture search puzzles to improve
eye scanning at near distances.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Why does a patient with a right-sided stroke have a higher risk
for injury due to mobility difficulties?
Pexels, CC0
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Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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•
Difficulty in judging position, distance,
and rate of movement
•
Impulsive, impatient, and deny problems
related to stroke
•
Respond best to directions given verbally
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Nursing interventions:
•
Break tasks down into simple steps
•
Control the environment, improve
lighting, and limit clutter and obstacles
•
Non-slip footwear
•
Address one-sided neglect
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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•
Slower in organization and
performance of tasks
•
Impaired spatial discrimination
•
Have fearful, anxious response
to stroke
•
Respond well to nonverbal cues
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Aphasia
Dysphasia
Dysarthria
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Aphasia
?
ABC
?
ABC
Receptive aphasia
Expressive aphasia
Global aphasia
Difficulty in understanding
written and spoken
language
Loss of the ability to
produce spoken or written
language
Severe form of receptive
and expressive language
skills
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Strategies for Communication
1.
attention before you start.
2.
Minimize or eliminate background noise
(TV, radio, other people).
3.
Keep your own voice at a normal level,
unless the person has indicated
otherwise.
4.
Keep communication simple, but adult.
Simplify your own sentence structure and
reduce your rate of speech. Emphasize
to the
person with aphasia.
5.
Give them time to speak. Resist the urge
to finish sentences or offer words.
https://www.aphasia.org/aphasia-resources/communication-tips/
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Dysphasia
•
Difficulty with communicating
•
Often used interchangeably with aphasia
•
Nonfluent dysphasia
speech
•
Fluent dysphasia speech is present but
not consistently meaningful
minimal and slow
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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AB
C
Dysarthria
•
Difficulty with the muscular
control of speech
•
Affects the mechanics of speech,
not the meaning
•
Problems with pronunciation,
articulation, or phonation
CN© May 13, 2019 OpenStax. https://cnx.org/contents/Ax2o07Ul@16.4:5MG__z6R@9/17-5-Sound-Interference-and-Resonance-StandingEdosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
Waves-in-Air-Columns, CC BY 4.0, edited
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Dysarthria
What is the difference between dysarthria, dysphasia and
aphasia?
Dysarthria
Dysphasia
Aphasia
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Stroke and Emotions
•
After a stroke, patients may have
difficulty controlling emotions.
•
Emotions may become exaggerated or
unpredictable.
•
The challenges of residual functional
impairments and changes may also
become more difficult due to depression.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Intellectual Function
There is a wide range of possible impairment with memory
and judgement.
Collaboration with therapists, family/significant others, nurses
and HCPs is essential to individualize plan of care.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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In a Nutshell
 Goals in telemetry/med surg units are to
minimize possible complications from stroke.
 Facilitate optimum functioning and sensoryperception for the patient after stroke.
 Communication, emotional control, affect,
and intellectual function can all be negatively
impacted following a stroke.
 Continue collaborative interdisciplinary
evaluation and safe discharge
planning including physical therapy, speech
therapy, occupational therapy, social work,
and registered dietician.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Cardiovascular Interventions
Goal: Maintain homeostasis and adequate tissue perfusion
•
Monitor vital signs and cardiac rhythm.
•
Monitor intravascular fluid volume (avoid hyper/hypovolemia).
•
Auscultate lung sounds for signs of pulmonary edema.
•
Auscultate heart sounds for murmurs or S3 or S4 heart sounds.
•
Maintain blood pressure within HCP determined range.
•
Administer antihypertensive medication.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Cardiovascular Interventions
Patients who experience strokes may also
have cardiac disease.
Watch for higher risk of fluid volume overload
and blood pressure control.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Cardiovascular Interventions
Goal: Maintain homeostasis and adequate tissue perfusion
•
Prevent thrombus formation or venous thrombus formation (VTE).
•
Paralyzed lower limbs present highest risk for VTE.
•
Encourage mobility.
•
Utilize compression socks.
•
Position to prevent edema in extremities.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Venous Thromboembolism (VTE)
VTE is a condition in which a blood clot forms most often in
the deep veins of the leg, groin or arm (known as deep vein
thrombosis, DVT) and travels in the circulation, lodging in the
lungs (known as pulmonary embolism, PE).
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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In a Nutshell
 Patients who have a stroke often have
cardiovascular disease.
 Monitor blood pressure to remain within
HCP ordered parameters.

appropriate.
 Watch closely for signs of fluid volume
overload and signs of thromboembolism.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Respiratory Interventions
Goal: Maintain adequate oxygenation for tissue perfusion
•
Assess lung sounds posteriorly and anteriorly.
•
Monitor and assess oxygenation.
•
Provide supplemental O2 as required.
•
Encourage mobility, and deep breathing.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Respiratory Interventions
Goal: Maintain adequate oxygenation for tissue perfusion
•
Monitor patient for signs of respiratory complications such as:
•
Atelectasis
•
Aspiration pneumonia
•
Pulmonary edema
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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In a Nutshell
 Patients are at risk for developing
respiratory complications such as
aspiration, atelectasis and pulmonary
edema, after a stroke.
 Monitor fluid volume status closely, assess
breath sounds posteriorly, keep HOB
elevated when eating/drinking, and
encourage mobility, and deep breathing.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Gastrointestinal (GI)
Goal: Promote normal bowel function and
minimize risk of constipation/impaction
Constipation is the most common bowel problem.
•
Use prophylactic stool softeners or fiber.
•
problems or fluid volume overload.
•
Physical activity promotes bowel function.
•
Bowel retraining may be needed.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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•
•
Offer regular opportunities to go to the
bathroom:
•
Every 2 hours
•
During gastrocolic reflex
(30 40 minutes after a meal)
Add extra suppositories or stimulation
if
immobility too severe
Bowel retraining
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Gastrointestinal (GI)
Goal: Promote adequate and safe nutrition
•
Collaborate with the clinical dietician and HCP to complete nutritional
needs assessment.
•
Collaborate with speech therapist for any concerns with swallow
evaluation.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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•
position for all feeding.
•
Assess gag reflex gently before first
feeding.
•
If gag reflex not adequate, do not feed
patient until assessed by speech therapy
and a safe plan is developed.
•
Also assess for chewing, and pocketing
before beginning oral feeding.
•
Follow every meal with oral hygiene.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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In a Nutshell
 Constipation is the most likely bowel
problem after a stroke.
 Patients should stay appropriately hydrated,
use stool softeners, and be as mobile as
possible.
 Bowel retraining may be required to help the
patient return to a normal bowel elimination
pattern.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Renal/urinary
Goal: Promote normal bladder function and the safest,
highest level of patient independence
•
Some patients may have poor bladder control in the acute stage of
stroke.
•
Avoid use of indwelling catheter, or discontinue as soon as possible
due to risk of infection.
•
Support and facilitate normal bladder function through bladder
retraining as needed.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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•
No large amount of fluids right before
going to bed
•
Keep patient well-hydrated during the
day, with frequent toilet opportunities
•
Walk him to the bathroom, make sure he
is safe
•
Walking to the bathroom keeps the
patient mobile
Bladder retraining
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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•
Ultrasound can tell how well patient
empties his bladder, and if he needs
to empty his bladder
•
Can be done on the bedside
Bladder ultrasound
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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In a Nutshell
 Avoid the use of indwelling catheters as
much as possible to minimize risk of
infection.
 Bedside bladder ultrasound can help identify
residual problems.
 Bladder retraining may be necessary to help
patient reestablish normal elimination
patterns.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Skin
Goal: Prevent skin breakdown (aka pressure sores,
decubitus ulcers, or bedsores)
•
Stroke patients can have a higher risk of skin breakdown.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Risk for Skin Breakdown
Skin breakdown leads to
pressure ulcers which are an
area of the skin or underlying
tissue that is damaged because
of loss of blood flow to the area.
SharonMcCutcheon, CC0
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Risk for Skin Breakdown
Risk factors:
•
Immobility
•
Sitting/lying
•
Swelling
•
Poor circulation
•
Things that compromise circulation:
smoking, poor nutrition, overweight
or underweight, incontinence, and
advanced age
SharonMcCutcheon, CC0
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Positioning
Protect the paralyzed side
Pressure relief
Proper skin hygiene
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Positioning
Lying on
left side
Lying on
right side
Sitting up
Lying on
back
Source: Mark Smith, Clinical Specialist Physiotherapist for Stroke, NHS Lothian; adapted by Lecturio
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Sitting in
bed
In a Nutshell
 Stroke patients are at a higher risk for
skin break down or pressure ulcers.
 Remember the 4 Ps for minimizing risk of
skin breakdown
• Positioning
• Protect the paralyzed side
• Pressure relief
• Proper skin hygiene
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Musculoskeletal/mobility
Goal: Promote optimum mobility and function
•
Symptoms are caused by the destruction of motor neurons in the
pyramidal pathway (nerve fibers from the brain that pass through the
spinal cord to the motor cells).
•
After a stroke, patients are most likely to experience motor function
impairment in mobility, respiratory function, swallowing, speech, gag
reflex, and self-care abilities.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Musculoskeletal/mobility
Goal: Promote optimum mobility and function
•
Early and safe mobility for joints and muscles will help minimize
deformity and improve function.
•
Range-of-motion and positioning in the most acute phases with the
goal of mobility as early as possible to prevent deformities from
paralysis.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Motor Deficits
Muscle tone
Akinesia
Muscles can weaken
and lose mass.
The patient cannot move their
voluntary muscles as they wish.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Motor Deficits
Initially
Progresses
Hyporeflexia
Hyperreflexia
Muscles may be flaccid (days to
weeks) dependent on amount of
nerve damage
Muscles become spastic due to
interruptions of upper motor neurons.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Paralysis Deformities
•
Specific deformities or contractures may develop
on the weak or paralyzed side.
•
Patients are going to have an internal rotation of
the shoulder, flexion contractures of the hand,
wrist, and elbow, external rotation of the hip, and
plantar flexion of the foot.
•
Collaborate with physical therapy for plan of care to
prevent/minimize deformities.
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Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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In a Nutshell
 After a stroke, patients likely to
experience motor function impairment
and an increased risk for falls.
 Specific deformities or contractures may
develop on the weak or paralyzed side
 Reflexes can be initially hyporeflexia and
progress to hyperreflexia.
 Muscle control can be initially flaccid and
progress to spasticity.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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Ongoing Discharge Planning
1
Interdisciplinary collaboration to develop next best step
2
Functional safety
3
Health promotion and reduction of modifiable risk factors
4
Coping
5
Changes in roles and responsibilities
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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•
Functional safety
•
Health promotion and reduction
of modifiable risk factors
•
Coping
•
Changes in roles and
responsibilities
•
Medication education
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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In a Nutshell
 The experience of an acute stroke has
physical, emotional, and functional
impact on the patient and their families.
 Interdisciplinary collaboration from the
stay are critically important to develop
the most effective discharge plan to
home or another level of care after the
telemetry/med surg unit.
 Lifestyle management of modifiable
risk factors will improve the quality of
life for the patient and minimize the risk
of developing complications or another
stroke.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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This document is a property of: Edosa Erhunmwuosere
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.
Edosa Erhunmwuosere, eerhunmwuosere7666@live.hccc.edu
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