Education and Health Promotion

•r Health promotion should focus on stroke prevention and target adherence and education
‣ Uncontrolled hypertension
‣ Adherence to anti-hypertensive medication and importance of taking it
‣ Regular BP screening
‣ Uncontrolled diabetes
‣ Antiplatelet therapy with aspirin
‣ Anticoagulants for AF
‣ Assistance to quit smoking, including referral
• Education on early warning signs of TIA or stroke to patient, family and friends (FAST) and what to do

Respiratory System

•i Stoke patients vulnerable to aspiration pneumonia (due to impaired consciousness or dysphasia)

• Patients to be kept NBM until assessed by speech therapist and dysphasia cleared
• Nursing interventions are individualised to meet patients needs include:
‣ Frequently assessing airway latency and function
‣ Provide oxygen
‣ Suction
‣ Promotion of mobility
‣ Repositioning patient to prevent aspiration
‣ Encourage deep breathing
• On patients with mechanical ventilation- oral care 2/24 reduces pneumonia risk
• NOTE: ICP can also increase with coughing and suction for patients with aneurysm so care for airway avoiding these
exercises

Neurological System

• Monitor vital signs and neurological changes

• Increase in BP can indicate increased ICP
• Decrease it LOC can indicate increase ICP
• ICU Care: Monitor cerebral perfusion pressure
‣ Ways to monitor neurological changes include:
‣ Clinical Assessment Tool for stroke severity: NIHSS
‣ MSE
‣ Pupillary response
‣ GCS
‣ Monitor vital signs

Cardiovascular System

•r Most patients with stroke have decreased cardiac reserves or cardiac disease
n• Central venous pressure, pulmonary artery pressure and harmony amid monitoring to monitor
‣ Fluid balance for risk of fluid retention and dehydration
‣ BP variations (increased BP common as body increases cerebral blood flow)
‣ Cardiac function
e• Nursing Interventions:
‣ Monitor vital signs
‣ Monitor cardiac rhythms
‣ I and O fluid charts
‣ IV infusions and adjusting fluid intake
‣ Monitor lung sounds for crackles (pulmonary congestion )
‣ Monitor heart sounds for murmurs or S3 and S4 heart sounds
• Patient at risk of Venous Thrombo-Embolism (VTE) post-stroke
‣ Prevention: keep patient mobile as possible (ROM exercises), positioning to prevent oedema, pressure devices
‣ Assessment: measuring leg and calf daily, observe swelling of extremities, and aske paient if they are experiencing
pain or warmth in extremities

Musculoskeletal

•
x Nursing Goal: maintain function whilst preventing muscular atrophy
• Hemiparetic side needs special attention
‣ Position each join higher than the proximal joint to prevent oedema
‣ Positioning and movement of shoulder to prevent shoulder pain
• Nursing interventions to optimise musculoskeletal function include (as per physio recommendation on an individual basis):
‣ Trochanter roll at hip to prevent external rotation
‣ Hand splints to prevent hand contracture
‣ Arm support with sling to prevent shoulder displacement
‣ Avoid pulling the patient by affected arm (risk of shoulder displacement)
‣ Posterior leg splints

Integumentary System
• Skin is susceptible to breakdown due to:
‣ Loss of sensation
‣ Decreased circulation
‣ Immobility
• Exacerbated by:
‣ Advanced age
‣ Poor nutrition
‣ Dehydration
‣ Oedema
‣ Incontinence
• Nursing management for prevention of skin breakdown:
‣ Pressure injury prevention: special mattress, pillows under bony prominences
‣ Pressure Injury prevention: positioning **no more than 2 hours in any position**
‣ Skin care: hygiene
‣ Emollients for dry skin
‣ Mobility
• NOTE: DO NOT massage damaged areas

Gastrointestinal System
• Constipation is common following a stroke
‣ Dietitian to assess nutritional and fluid status
‣ use of stool softeners/ high fibre/ psyllium
‣ Increase mobility to promote bowel movement
‣ Bowel management program: regular bedpan or taking patient to toilet regularly
‣ Enema can cause increased ICP as they cause vagal stimulation

Urinary System

•r In acute stage of stroke urinary incontinence is common

•
n Avoid use of a catheter (risk of UTI and delayed bladder retraining
• Functional incontinence due to communication difficulty
• Bladder retraining program
‣ Adequate fluid intake
‣ Scheduled toileting 2/24
‣ Assessment of bladder distension

Nutrition

• intestine nutritional support improves motor recovery

•n speechie to perform comprehensive assessment (for dysphasia)
• NOTE: stroke patient must have swallow screening within 24hours of admission
• Swallow screening:
‣ Use approved screening tool (ASSIST tool)
‣ Patient must retain alertness for 20min
‣ Elevate head into upright position (unless contradicted)
‣ Give patient a teaspoon of water to swallow (use prompts from screening tool)
‣ Coughing or spillage of fluids = dyspahgia = cease examination and refer
‣ Successful screening = oral intake can initiate