stroke nursing intervention
Topics: Stroke / Pages: 5 (1229 words) / Published: Oct 26th, 2013

Stroke treatment, Alzheimer

Most common cause of stroke-thrombus by atherosclerosis Embolus-2nd most common
Hemorrhage-90yr old+, cerebral artery problem
ER care
• Thrombus and Embolus-anticoagulant
• Hemorrhage-heparin
• Know the cause and prioritizing the intervention
• Airway-Hemiplegia Pt easily gets tongue obstruction
• Turn the head to the side
• 10-30* HOB for better venous return
• O2
• IV
• VS
• Assessment-Neuro, pupil, Glasgow coma scale, Ask Pt Q ex) Raise your hand, Squeeze my hands.
• 48-72 time line is so important
• TPA clot buster should be administer in 3 hr

Respiratory system-Airway
• Side lying position to prevent aspiration
• After 48 hr, Pt may breathe their own and Doc will start tracheal tube
• Be sure the suction machine is ready
Neuro-Increased ICP
• Closely monitor Increased ICP
• The most important assessment? LOC
• Pupil check
• Mental status
• The earliest sensitive assessment test for mental status change? LOC
Cardio vascular
• Fluid management
• Fluid retention
• Over hydration result in overload and cause cerebral edema
• I&O closely, carefully, constantly monitoring
• High risk r/t inflammation of vein-DVT on affected, weak side of extremities
• No exercise? Easy to get a clot, thrombus
• How do we prevent DVT? Keep Pt to move their extremities
• Keep them moving, AROM, PROM, Ambulation; Pt can move their affected side by helping with non affected side.
• Poisitioning-Change every 30min-2hr
• Prevent dependent edema
• Foot pump
• Ted hose
Muscular skeletal system
• Prepare and plan Pt’s discharge starts at Admission
• Prepare plan of completion starts at Admission
• When you don’t use the muscle, you will lose it
• Prevent muscle atrophy,
• Paralyzed side-special attention with positioning, use lots of pillow
• Elbow should be higher than heart for better venous return
• Extremities muscles are stronger
• More than 5 min exercise/day
• Food drop &

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