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(Roa-Helen) Monitoring Stroke Patients in The

During the acute phase after a stroke, victims must be closely monitored in an intensive care unit to focus on their survival and prevent further complications. Nurses should monitor the patient's status using scales like the NIHSS and Glasgow Coma Scale, as well as vital signs like pulse, blood pressure, temperature, oxygen saturation, and blood glucose to avoid issues like hypotension, hypoglycemia, hyperglycemia, hypoxia, and hyperthermia which can damage brain cells. Nurses must also monitor for potential complications including intracranial problems, seizures, hypoxemia, cardiac issues, hypertension, pulmonary embolism, dysphagia, aspiration pneumonia, and urinary tract infections.

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48 views8 pages

(Roa-Helen) Monitoring Stroke Patients in The

During the acute phase after a stroke, victims must be closely monitored in an intensive care unit to focus on their survival and prevent further complications. Nurses should monitor the patient's status using scales like the NIHSS and Glasgow Coma Scale, as well as vital signs like pulse, blood pressure, temperature, oxygen saturation, and blood glucose to avoid issues like hypotension, hypoglycemia, hyperglycemia, hypoxia, and hyperthermia which can damage brain cells. Nurses must also monitor for potential complications including intracranial problems, seizures, hypoxemia, cardiac issues, hypertension, pulmonary embolism, dysphagia, aspiration pneumonia, and urinary tract infections.

Uploaded by

alsamixers
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Monitoring Stroke Patients in the ICU or Stroke Unit

What Nurses should know:


During the acute phase, efforts focus

on the survival needs and preventions of further complications Often, stroke leaves victims in an unstable medical condition, acute stroke victims must be closely monitored in an ICU

Status

- NIHSS - Sensorium, Pupil, Eye movement, Respiration, Motor Response - Glasgow Coma Scale (GSC)

2. Monitor Vital Signs:


- Pulse, Blood Pressure, Temperature, Oxygen Saturation, Blood Glucose and Respiratory Pattern

To save brain cells : Avoid 5 H (Hypotension, Hypoglycemia, Hyperglycemia, Hypoxia, Hyperthermia)

3. Monitor for Potential Complications: a. Intracranial Problems - brain edema raise head of bed to 2030 degrees, reduce increase in body temperature - bleeding- seen using brain CT Scan - increased intracranial pressure stool softeners to prevent straining - seizures - IV antiepileptic medication is given

- continuous pulse oximetry is required, if hypoxemic < 92% - treat with supplemental O2 @ 2-4 L/min - maintain patent airway and provide supplemental oxygenation as indicated - if pt. is unconscious, insert an artificial airway (endotracheal tube) and start mechanical ventilation

- pt. need continuous cardiac monitoring - stroke pts. often present with existing cardiac problemsarrhythmias and myocardial infarction - ECG and cardiac markers are taken - hypertension - maintain at <180/105 mmhg - pulmonary embolism - early pt. mobilization, external compression devices (antiembolic stockings) and anticoagulants

- Dysphagia- check for gag reflex before giving food, insert Nasogastric Tube if oral feedings is not possible - Infections: - Aspiration Pneumonia - developed from microbes aspirated from the mouth and throat - Urinary Tract Infection- pt. is incontinentneeds indwelling catheter - cause of infections, prompt for urine screening

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