Stoke Flashcards
How to manage/NI?
–
Monitor signs of respiratory compromise /ABC
Decreasing LOC increased for tongue dropping back causing obstructed airway
O2 Adminsration
tissue oxygen needs
Monitor VS: BP, Pulse, RR, Temp
BP may be increased due to a compensatory mechanism to keep cerebral perfusion
treatment indicated if greater thanh 220/120 mm hg
Hyperthermia increase ICP negative outcome
Assess nuero status / neuro checks
q15mins to determine progression of treatment
LOC
Glascow coma scale
NIH Scale
Establish/maintain IV access
for medication adminstration
anticipate antihypertensensive meds
thrombolytic (RO hemorrhagic Stroke)
position head midline/ raise HOB
decreases IcP
improves venous drainage
Decreases risk for aspiration
Monitor EcG/ Cardiac montiring
to detect any life threatening dysrhythmias
Monitor for signs of Increased ICP
Complication of stroke
seizure precaution
complication of stroke
pad siderails
have sunction available
oxygen avialable
Monitor for N/V
to prevent aspiration
provide skin care
Assess Bladder/Bowl
loss of sensation on half of body;Hemiplegia
incontinence may occur after stroke
teach patient to scan surrounding
possibility of hemaniopsia
maintain NPO
swallow eval first . increased risk for aspiration
provide referral for speech, physical, occupation therapies
risk for aphasia (receptive, expressive)
Provide ROM activated/ passive
increased risk for muscle tone decrease
WHAT SHOULD I REPORT?
LOC
2re
BP,Pulse, Temp
3re
Resp status
4re
headache
5re
mobility )Hemiplegia
6re
speech patterns
WHAT SHOULD I ANTICIPATE ?
02
2AN
ECG / CARDIAC MONITORING
