The goals for collaborative care during the acute phase of stroke are preserving life, preventing further brain damage and reducing disability. Acute care begins with managing ABCs .
This is a nursing priority. Advancing age and immobility increase the risk of atelectasis, pnuemonia, and aspiration pnuemonia. Airway can occur due to problems with chewing and swallowing, or the tongue falling back Some patients may require intubation and mechanical ventilation depending on the brain regions affected by the stroke.An oropharyngeal air may be used to support airway maintenance and enable suctioning.
Nursing interventions include:
- Assessing airway patency
- Positioning to prevent aspiration
- Caution should be used with encouraging coughing as this can increase ICP
Information on respiratory assessments can be found here
Neurological status should be monitored frequently to detect changes in ICP, extension of stroke, or recovery.
- Vital signs
- ICP monitoring
Information on neurological assessment can be found here
Cardiac efficiency may be compromised by fluid retention, over-hydration, or dehydration. ADH and aldostorone production during stress can cause fluids to be retained. This can result in an increasing ICP. IV therapy should be careful monitored, as well as input and output.
- Monitor cardiac rhythm
- vital signs
- monitor lung sounds for crackles
- monitor heart sounds
The patient is at increased of DVT especially in the weaken side. Active range of motion exercises should be taught if the patient has voluntary movement in the affected side. Passive range of motion exercises should be done severe times a day for the patient with hemiplegia. Use of TEDs and enoxaparin can prevent DVTs.
The goal is to maintain optimum function by preventing joint contractions and muscular dystrophy. In the acute phase range of motion exercises and positioning are important
- Patient teaching of ROM exercises (active or passive)
- Position each joint higher than the proximal joint to prevent oedema
- trochanter roll at the hip
- hand cones to prevent contracture
- arm supports eg slings
- posterior leg splints, footboard,
- Hand splints
Stroke patients are susceptible to skin breakdown due to loss of sensation, decreased circulation and immobility.
- Pressure relief by position changes
- goo skin hygiene
- emollients applied to dry skin
- early mobility
The ideal position change schedule is side-back-side with a maximum of 2 hour duration for any position. The patient should only be positioned on the weak side for 30 minutes. Pillows can be used to prevent pressure areas on the heels.
A guide to stroke patient positing can be found below.
The stress of illness contributes to a catablic state that cn interfere with recovery. Nutritional needs to be assessed and the patient may receive IVF to maintain fluid and electrolyte balance. The patient will be NBM until a swallowing assessment can take place. The gag reflex can be checked by gently stimulating the back of the throat with a tongue depressor.
- Mouth care before feeding stimulates sensory awareness
- Position patient high-fowler for 30 minutes following feeding
- Avoid milk as this thickens secretions
- Prophylaxis laxitives
- Monitor for faecal impaction
- Monitor fluid input/output
- Encourage mobility as tolerated
Poor bladder control can result in incontinence during the acute phase of stroke.
- Adequate fluid intake
- Schedules toileting every 2 hours
- note signs of restlessness (may indicate need to urinate
Here is some info on incontinence management
The patient needs to be assessed for the ability to speak and understand. If the patient can not understand words, gestures may be used.
- Speak slowly and clearly
- Decrease environmental stimuli
- Keep questions simple
- Do not interrupt the patient
- Do not pretend to understand the patient when you do not
- Speak with normal tone and volume
- Allow rime for the patient to process the information
- Prepare a schedule to organise the patients day
- Do not push communication when the patient is uspet or anxious
Here’s a video exploring communicating with a patient with aphasia
And an information sheet with tips on communicating.
Homonymous hemianopsia is a common problem after stroke. A patient who disregards objects in part of the visual filed should alert the nurse.
- Arrange items within the patients perceptual field
- Arrange food so it’s all on the left or right side
Neglect syndrome may also occur which increase the inattention to the weak side of the body.
- Remove safety risks
- Arrange patients environment to prevent injury
- lower the height of the bed
- Use safety rails