Nursing assessment for stroke patients

Sun0408, ASN, RN · May 7, 2014

Nutritional needs, emotional needs, communication, self care, etc... Strokes can be detrimental to the pt and their families. This should help you some :) Esme has some great tips on careplans, do a search and you will find lots of threads on the subject.

Episteme · May 8, 2014

STROKE PROTOCOL... HELLO??? So in this scenario, a (what?) family member student nurse... is just stolling around (the hospital? the home?) and sees gramps slumped in a chair paralyzed and aphasic.

There is no finesse to this. There is ONE thing to do. Call 911 (or rapid response in the hospital) and get the man to the care he needs. TIME IS BRAIN.

Now... if we want to have a nice little pedagogical dialogue about what to do with gramps after he's had his tPA, and spent the night in the ICU... then we can talk about it. But if you're being led to believe that a nurse in this situation is going to conduct a head to toe physical and assemble defining characteristics and articulate two nursing diagnoses using proper NANDA-I syntax then select outcomes and actions...

Your instructor is setting up a situation where you are learning the wrong lessons.

itsmejuli · May 8, 2014

Why are you asking for help with this? Did you read your text book? Research online?

You'll learn more from doing your own research.

GE90 · May 8, 2014

Thx!

The biggest problem I'm having is that the assignment do not allow us to say sth like "the patient clearly has a stroke" / "He've been diagnosed with stroke" while asking us to provide a care plan for him. I can't even put down "Strokes can be detrimental to the pt and their families"! :cautious:

And the assignment didn't tell us how's the patient doing after admission, if I don't know this how the hell am I gonna write a discharge plan for him?!

Nursing education is Australia is really stupid

GE90 · May 8, 2014

Nah we can't say "stroke protocol or patient has a stroke" as "we are not doctors, we don't diagnose", said by my tutor. :no:

I agree with what you said about wrong lessons..

GE90 · May 8, 2014

Thx bro, I'm doing my research now! :smug:

Esme12, ASN, BSN, RN · May 8, 2014

Thx!
The biggest problem I'm having is that the assignment do not allow us to say sth like "the patient clearly has a stroke" / "He've been diagnosed with stroke" while asking us to provide a care plan for him. I can't even put down "Strokes can be detrimental to the pt and their families"!
And the assignment didn't tell us how's the patient doing after admission, if I don't know this how the hell am I gonna write a discharge plan for him?!
Nursing education is Australia is really stupid

You write an assessment. Think about the physical symptoms. How did this patient present.

The patient was found slumped, difficulty communicating and speech issue, cannot move his arms and drooped facial expression. Instead of saying "Stroke you say.. a patient with bilateral inability to move their arms would need...a patient that cannot speak (aphasia...Types of Aphasia)

Start there...

Patient presented after being found slumped over. Initial assessment shows that the patient (head to toe) has a facial droop that appears to be isolated to one side (does your assignment mention which side? that can help you discover which side the insult/damage [CVA] has affected). The patient is experiencing difficulty speaking (HINT here: what kind of CVA affects speech) does this affect their swallowing? Are they at risk for aspiration? Can they swallow their saliva? State the patient appears to be unable to move the upper extremities bilaterally. Here is a start point....

The brain is an extremely complex organ that controls various body functions. If a stroke occurs and blood flow can't reach the region that controls a particular body function, that part of the body won't work as it should.
If the stroke occurs toward the back of the brain, for instance, it's likely that some disability involving vision will result. The effects of a stroke depend primarily on the location of the obstruction and the extent of brain tissue affected.
Right Brain
The effects of a stroke depend on several factors, including the location of the obstruction and how much brain tissue is affected. However, because one side of the brain controls the opposite side of the body, a stroke affecting one side will result in neurological complications on the side of the body it affects. For example, if the stroke occurs in the brain's right side, the left side of the body (and the left side of the face) will be affected, which could produce any or all of the following:
Paralysis on the left side of the body
Vision problems
Quick, inquisitive behavioral style
Memory loss
Left Brain
If the stroke occurs in the left side of the brain, the right side of the body will be affected, producing some or all of the following:
Paralysis on the right side of the body
Speech/language problems
Slow, cautious behavioral style
Memory loss
Brain Stem
When stroke occurs in the brain stem, depending on the severity of the injury, it can affect both sides of the body and may leave someone in a ‘locked-in’ state. When a locked-in state occurs, the patient is generally unable to speak or achieve any movement below the neck.

Effects of Stroke

Now...what else should you consider...you can say the with the presenting symptoms other information necessary would be a fuller assessment. Pupils response, can the patient swallow. Can they move lower extremities. DO they seem aware of their surrounds and understand what is being said versus not interaction with environment (patient doesn't track movement).

Having this assessment what conditions could contribute to this? List them

What treatment might be considered for this presentation?

What is the most common cause of this type of diagnosis that could accompany this assessment?

How would any physical disability that is permanent affect the patient, his job and his family?

What predisposing factors/diseases/conditions might this patient have and need to be considered while caring for this patient?

What would need to be considered for this patient upon discharge if these symptoms are permanent?

How would you obtain services?

Right-side Stroke

This patient cannot move both arms could there be a more serious insult/damage to the brain....Brain stem.

This is about the mental check list that every bedside nurse goes though in her/his brain when the patient presents to the emergency apartment or you walk into their room and find them.

Now tell me what you think....

Episteme · May 8, 2014

I think this is an excellent explanation and run down Esme. But it seems the OP is unwillingly in some game where the he/she is not allowed to say "stroke". Maybe not even "brain"?

To the OP: If your patient has suddenly lost consciousness (doesn't matter why) you have to protect the airway. End of story. So pulmonary and airway assessments. Next you have to protect him from careening out of the chair... he can't move himself. You have to provide all of his physical safety. If your instructor won't let you say "stroke" you have to approach it the way you would any patient with a sudden change in consciousness.

Esme12, ASN, BSN, RN · May 8, 2014

The stroke are links to references....not actual suggestions for usage of the word....LOL

nurseprnRN, BSN, RN · May 8, 2014

Mobility, safety awareness, cognition, memory, executive function, home safety/environment including caregivers ...

GE90 · May 10, 2014

Damn....I think I might have screwed up the assignment.

I wrote i would recommend neurological and musculoskeletal assessment due to potential CVA to see what interventions I will need.

Then I put dyspnea hyperca/hypoxemia/aphasia/communication skills/mental health into [patient's health problems] and said the [interventions] i'm gonna apply are monitoring vital signs, prescribe drugs or o2 therapy if necessary, hygiene support, emotional support, assistance for eating like NGT, referral to pt/ot/gp/social worker/speech therapist/

I don't want to fail :arghh: