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04.06 Stroke Nursing Care (CVA)

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Overview

  1. Prevent further brain tissue damage
  2. Optimize functional ability

Nursing Points

Nursing Concepts

  1. Monitor level of consciousness
    1. (refer to LOC lesson)
  2. Monitor neurological status
    1. (refer to Neuro Assessment lesson)
  3. Monitor for evidence of Vasospasm or Re-Bleed
  4. Seizure Precautions
    1. Blood = irritating to tissues and vessels
  5. Maintain quiet, calm environment
    1. Minimize ICP
    2. Decrease frustration
  6. Assess need for assistive devices
    1. Rolling Walker
    2. Cane
  7. Involve Physical, Occupational, and Speech Therapists
  8. Specific Interventions
    1. Aphasia
      1. Provide time to respond
      2. Repeat names of objects, people (reorient)
      3. Picture board
      4. One instruction at a time
    2. Hemianopia
      1. Instruct to turn head to see entire visual field
      2. Approach only from unaffected side
      3. Provide food and objects from unaffected side
    3. Dysphagia
      1. Speech Therapy – swallow evaluation
      2. Keep NPO until cleared by Speech Therapy
      3. Sit upright when feeding
      4. Follow diet prescribed by Speech Therapist

Patient Education

  1. Purpose for NPO / ST evaluation
  2. Risk factors, especially modifiable
  3. Smoking Cessation!!
  4. Medication instructions (especially anticoagulant or nimodipine)
  5. Warning signs for stroke, call 911
  6. Follow-Up with Neurologist

Reference Links

Study Tools

Video Transcript

Okay guys, here’s the nitty gritty – let’s talk about your role as a nurse taking care of patients who have had or are having a stroke.

So our priorities for these patients are monitoring and safety. We’re going to monitor their level of consciousness and neurological status including orientation, strength and pupils. If a patient has just arrived to the emergency department we’ll do this neuro check every 15 to 30 minutes for a couple of hours and then we’ll do them hourly after that. Make sure you go back to the neuro assessment lessons to get a refresher on how to do those assessments. Now sometimes once a patient has had a stroke we tend to pull back on how often we do our neuro assessments. But if the patient has a vasospasm or re-bleeds, we will start seeing new stroke symptoms, or seeing their symptoms return on days 2 through 5. So we need to keep a close eye on their neuro status even after we think they’ve recovered.

As far as safety, remember that patients who have had a stroke are at risk for seizures, so we need to put them on seizure precautions. That means padding the side rails, having suction available, giving the antiepileptic medications, and possibly having Ativan at the bedside. We’ll maintain a quiet calm environment, not only to minimize their ICP, but also to minimize any frustration they may have with their symptoms. Anytime you have a patient with a hemianopia or a visual field loss, we will approach them and bring them things only from their unaffected side and teach them to turn their head so they can see everything. If they have residual weakness, we will provide assistive devices like walkers or canes and we make sure to involve physical therapy and occupational therapy so that these patients are safe when they get up to start ambulating. Because of the dysphagia we will also get speech therapy involved to assess their ability to swallow.

So the most common residual effects, besides weakness, in stroke patients are aphasia and dysphagia. So let’s talk about couple of specific interventions for these problems. Remember that aphasia can be receptive or expressive, depending on whether they have difficulty comprehending or communicating. So we want to make sure we give them plenty of time to respond to our questions, it might just take them a minute to get the words out or to understand the question. We will repeat things and reorient them, both to person, place, time, but also to the names of things like “this is a pen” or “my name is Nichole, I’m your nurse”. We also want to make sure to give only one instruction at a time – this helps to prevent confusion and helps them to follow what we need them to do. So, instead of “I want you to sit up, swing your legs over the side of the bed, and stand up tall with your head up”. We’re gonna start with “Sit up.” We may even have to repeat it or use gestures. Then, once they’re up, we say “now, swing your legs towards me”. And so forth. So we keep it very simple. *click* Then another option we have is to use a word board or a picture board to help the patients with expressive aphasia be able to point to what it is that they need or to say yes or no to your questions. I once had a patient with expressive aphasia who could only say “you know…you know…”. We got her a word board like this one and she was so happy to be able to get her needs across!

Dysphagia is difficulty swallowing because of weakness in the muscles of the throat. In stroke patients the speech therapists have the final say as to whether or not it is safe for a patient to swallow after they’ve had a stroke. So we will keep the patients NPO until they’ve been cleared by speech therapy. If they do show that they are at risk for aspiration because they can’t swallow appropriately, we need to put them on aspiration precautions. This means smaller bites, sitting them up right when they’re feeding, and sometimes a special diet. The speech therapist will be able to tell you exactly what diet the patient needs. This picture is an example of a pureed diet. Many facilities even have little molds that they can push the pureed peas into so that they at least look like real food, which is nice.

Patient education for stroke patients is actually a core measure created by Joint Commission. There are certain things that we have to educate our patients on before they’re discharged after having a stroke. One of those is whatever their modifiable risk factors are. The most important one being smoking cessation. We will also teach them about their medications like statins or nimodipine. They also need to know how important it is to follow up with their neurologist and any warning signs of a stroke that they need to report. Again we teach them the FAST Mnemonic – Facial drooping, Arm weakness, Slurred speech, Time to call 911.

So just to recap – our priorities for nursing care include monitoring neuro status, including level of consciousness, pupils, strength, and the NIH Stroke Scale once you’re certified. We want to focus on their functional ability and optimize it by getting PT and OT involved and using assistive devices. We also want to pay close attention to their safety and prevent aspiration or Falls when they start ambulating. And finally we need to make sure that we educate the patient on their modifiable risk factors, their medication instructions, and warning signs of a stroke that mean that they need to call 911.

Make sure you check out the care plan and case study attached to this lesson to see more detailed nursing interventions and rationales and to better understand what caring for a patient with a stroke looks like. We hope that you have a better understanding of strokes and what your role is as a nurse, and that you feel confident and ready to identify a stroke and get help right away. We love you guys, let us know if you need anything or have any questions. Now, go out and be your best selves today. And, as always, happy nursing!

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