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Terms in this set (268)

Monitor vitals every 1-2 hours. Notify provider of a BP over 180/110 (can indicate ischemic stroke). Monitor & treat fever. Maintain Oxygen over 92% if patient has decreased LOC. Monitor ECG for cardiac arrythmias. Conduct cardiac assessment to detect murmurs & irregularities. Monitor for change in LOC. Monitor for hyperglycemia due to poor neuro outcomes. Elevate HOB at least 30 degrees, prevent extreme flexion/extension of head. Institute seizure precautions.
Assist patient w/communication if speech is impaired: supply w/picture board of commonly requested items/needs. Speak slow/clearly. Use one step commands, maintain eye contact, work w/speech therapist, give patient time to communicate.
Assist w/ safe feedings: swallow study before feeding, completed 4-24 hours upon ED arrival. (4 liquid consistencies will be recommended following the study. Thin, nectar-like, honey-like, spoon-thick). Eat in upright position, swallow w/ head slightly flexed forward. Place food in the back of mouth on unaffected side, suction at the bedside.
Prevent complications of immobility: ambulate asap, ROM every 2 hours, change position every 2 hours, elevate affected extremities, work closely w/Physical Therapy.
Care for one-sided neglect: observe & protect from injuries of the affected extremities. Teach patient to protect & care for affected extremity. Apply arm sling, dress affected side first, place affected extremity to midline & protect from danger, instruct patient to overlook the affected side periodically.
Maintain safe environment: use assistive devices during transfers.
If patient has homonymous hemianopsia: instruct patient to use a scanning technique when eating/ambulating, put items in the room within patients view.
Assist w/ADLs/OT/PT: OT to assess for adaptive aids. Provide frequent rest periods. Patient typically leans to the affected side; provide support. Shoulder subluxation can occur if the affected arm is not supported. Instruct patient to use the unaffected side to exercise the affected side. Don't pull on affected arm, promote self-care, add a task each day.
Airway: frequent monitoring of respiratory status including auscultation of lung sounds. Position the patient to minimize aspiration. HOB elevated 30 degrees, never supine. Lateral or semi-prone position. Suctioning, oral hygiene, chest physiotherapy & postural drainage, mechanical ventilation/intubation.


Mouth and Cornea Care: clean eyes with cotton balls moistened w/saline. Use artificial tears as prescribed. Implement measures to protect eyes; use eye patches cautiously as the cornea may contact patch.


Skin Integrity: assess skin frequently, especially areas with high potential for breakdown. Turn patient frequently. Carefully position patient in correct body alignment, perform passive range of motion to prevent contractures. Use splints, foam boots, trochanter rolls, and specialty beds as needed.


Thermoregulation: adjust environment & cover patient appropriately. Administer antipyretics as ordered. Use hypothermia blanket if needed. Give a cooling sponge bath, monitor temp frequently & use measures to prevent shivering.


Bowel and Bladder Function: assess for urinary retention & urinary incontinence. May require indwelling or intermittent catheterization. Initiate bladder-training program. Assess for abdominal distention, potential constipation, & bowel incontinence. Monitor bowel movements. Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated. Diarrhea may result from infection, meds, or fluid administration.



Sensory Stimulation and Communication: talk to touch patient & encourage family to talk to & touch the patient. Maintain normal day-night pattern of activity. Orient the patient frequently. Note: when arousing from coma, a patient may experience a period of agitation; minimize stimulation at this time (no crying family members, loud noises). Initiate programs for sensory stimulation. Allow family to ventilate feelings/concerns & provide support. Reinforce & provide consistent information to family. Referral to support groups & service for family.

Absence of complications: assess patient frequently, pay attention to minor changes, report changes to HCP in timely manner, communicate needs to healthcare team. Educate family. It is the nurse's responsibility to communicate with other healthcare providers (respiratory therapy, occupational therapy).
Monitor vitals every 1-2 hours. Notify provider of a BP over 180/110 (can indicate ischemic stroke). Monitor & treat fever. Maintain Oxygen over 92% if patient has decreased LOC. Monitor ECG for cardiac arrythmias. Conduct cardiac assessment to detect murmurs & irregularities. Monitor for change in LOC. Monitor for hyperglycemia due to poor neuro outcomes. Elevate HOB at least 30 degrees, prevent extreme flexion/extension of head. Institute seizure precautions.

Assist patient w/communication if speech is impaired: supply w/picture board of commonly requested items/needs. Speak slow/clearly. Use one step commands, maintain eye contact, work w/speech therapist, give patient time to communicate.

Assist w/ safe feedings: swallow study before feeding, completed 4-24 hours upon ED arrival. (4 liquid consistencies will be recommended following the study. Thin, nectar-like, honey-like, spoon-thick). Eat in upright position, swallow w/ head slightly flexed forward. Place food in the back of mouth on unaffected side, suction at the bedside.
Prevent complications of immobility: ambulate asap, ROM every 2 hours, change position every 2 hours, elevate affected extremities, work closely w/Physical Therapy.

Care for one-sided neglect: observe & protect from injuries of the affected extremities. Teach patient to protect & care for affected extremity. Apply arm sling, dress affected side first, place affected extremity to midline & protect from danger, instruct patient to overlook the affected side periodically.

Maintain safe environment: use assistive devices during transfers.
If patient has homonymous hemianopsia: instruct patient to use a scanning technique when eating/ambulating, put items in the room within patients view.

Assist w/ADLs/OT/PT: OT to assess for adaptive aids. Provide frequent rest periods. Patient typically leans to the affected side; provide support. Shoulder subluxation can occur if the affected arm is not supported. Instruct patient to use the unaffected side to exercise the affected side. Don't pull on affected arm, promote self-care, add a task each day.