VII. Nursing Management
Provide nursing care during the acute phase (48 to 72 hours ) of stroke
• Administer medications, which may include osmotic diuretics, corticosteroids, and anticonvulsants. To prevent further development, oral anticoagulant, and antiplatelet agents may be prescribed.
• Monitor for increased ICP.
Improving cerebral tissue perfusion
• Monitor closely for neurologic deterioration, and maintain a neurologic flow record
• Check blood pressure, pulse, level of responsiveness, papillary responses, and motor function hourly, monitor respiratory status and report changes immediately
• Implement subarachnoid precautions (immediate and absolute bed rest in a quiet, nonstressful setting, restrict visitors, except for family)
• Elevate head of bed 15 to 30 degrees or as ordered
• Avoid any activity that suddenly increases blood pressure or obstructs venous return (eg. Valsalva maneuver, instruct patient to exhale during voiding or defecation to decrease strain.
• Eliminate caffeine, administer all personal care and minimize external stimuli
• Apply elastic compression stockings or sequential compression boots. Observe legs for signs and symptoms of deep vein thrombosis (tenderness, swelling, warmth, and positive Homan’s sign).
Relieving sensory deprivation
• Keep sensory stimulation to a minimum
• Explanation restrictions to help reduce patient’s sense of isolation
Relieving anxiety
• Inform patient of plan of care
• Provide support and appropriate reassurance to patient and family
• Provide reality orientation
Teach the client’s family:
• Effective communication technique
• New ways of interacting with the client after discharge
• Ways to encourage the client in self-feeding
• Safety precautions
Help reduce pain and promote comfort
• Administer analgesics as prescribed
• Position the client to decrease discomfort
• For a client with subarachnoid hemorrhage, reduce externals stimuli, move him slowly, and turn his neck gently
Prepare the client for surgical intervention as appropriate, which may include:
• Carotid endarterectomy for client experiencing TIA
• Craniotomy for surgical clipping of aneurysm
Teach and assist with or perform range-of-motion (ROM) exercises to help maintain muscle tone and prevent contractures.
Assist the client with personal hygiene as necessary (hair washing and brushing, make up application, shaving)
Encourage the client to touch the paralyzed side and to participate in passiv ROM exercises as appropriate
Consider the client’s interests when planning daily activities
Plan the client’s care to allow for adequate periods of uninterrupted rest. Schedule therapy sessions after rest periods.
Provide a balanced diet, and assist the client with eating if necessary. Allow sufficient time for meals, place food so that the client can see it, and provide foods that are easy to handle.
Maximize the client’s opportunities for social interaction.
Consider the client’s interests when planning daily activities.
Teach the client how to use a walker, cane, or wheelchair as appropriate.