3 main assessments and interventions for acute ischemic stroke

  1. What I mean is what are the 3 main nursing assessments and 3 nursing interventions when your patient (who didn't have stroke) suddenly displays signs and symptoms of stroke and what are the rationales behind the assessments and interventions?

    Do you guys have any feedback regarding this:

    Assessments:
    a) LOC
    b) Vital signs (Esp. pulses, bp and respirations)
    c) Cranial shape (to know if it’s hemorrhagic or ischemic)
    d) PERRLA (Pupils are Equal, Rounded, Reacted to Light and Accommodation)
    e) Facial expressions
    f) Ctemps (esp. to assess for paralysis)

    Interventions:
    a) Position with head slightly elevated and in neutral position (Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion)
    b) Administer o2 (Reduces hypoxemia.)
    c) Administer heparin if ordered and if it’s hemorrhagic
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    2 Comments

  3. by   NICUismylife
    #1, never give heparin if it's hemorrhagic!!!

    You are on the right track, but I think you are over complicating it. One of the hospitals that I do clinical at has a stroke card that goes on our name badge that we can reference at any time.

    It states:
    "Act F.A.S.T

    Face: Ask person to smile, does one side droop?
    Do they have a sudden severe headache with no known cause, sudden blurred or loss of vision.

    Arms: Ask the person to raise both arms. Does one arm drift downward? Do they have a loss of balance or do they have dizziness?

    Speech: Ask the person to repeat a simple sentence. Does the speech sound slurred or strange? Do they have trouble talking or understanding?

    TIME: Stroke is a medical emergency. Call RRT"

    So, my advice to you, is to research those symptoms and interventions and figure out the rationale behind them.

    Good luck!
  4. by   Horseshoe
    Quote from Faye cute
    What I mean is what are the 3 main nursing assessments and 3 nursing interventions when your patient (who didn't have stroke) suddenly displays signs and symptoms of stroke and what are the rationales behind the assessments and interventions?

    Do you guys have any feedback regarding this:

    Assessments:
    a) LOC
    b) Vital signs (Esp. pulses, bp and respirations)
    c) Cranial shape (to know if it’s hemorrhagic or ischemic)
    d) PERRLA (Pupils are Equal, Rounded, Reacted to Light and Accommodation)
    e) Facial expressions
    f) Ctemps (esp. to assess for paralysis)

    Interventions:
    a) Position with head slightly elevated and in neutral position (Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion)
    b) Administer o2 (Reduces hypoxemia.)
    c) Administer heparin if ordered and if it’s hemorrhagic
    Please give your rationale for administering heparin to a person having a hemorrhagic stroke.

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