what should a nurse do if someone is having a stroke

If you suspect a stroke, immediately notify the attending physician, who will call for a stroke alert or code stroke. A stroke alert or code stroke should run as efficiently as a code blue. Nurses should have preassigned roles that include drawing blood for lab work, maintaining communication with the patient’s family, and communicating with physicians and computed tomography (CT) staff.

Full Answer

What should you do if you see someone having a stroke?

“If a witness sees someone develop symptoms of a stroke, the first step is always to call 911.

How has nursing care for stroke evolved over time?

As assessment tools, treatment protocols and overall care for acute ischemic stroke have evolved in recent years, best practice in nursing for care of the patient with a stroke continue to be revised and updated.

Do nurses know the warning signs of stroke?

As a nurse, your assessment of the patient’s signs and symptoms and your knowledge of stroke treatment are vital. All nurses should know the warning signs of stroke, teach patients and families about these key clues, and spread the word about the importance of getting immediate help.

Who should accompany a patient to a CT scan after stroke?

A nurse, physician, or both must accompany the patient (who should be on a monitor) to the CT scan. For patients with ischemic stroke, the goal is to rapidly restore brain perfusion to save ischemic but viable brain cells. Patients who receive tPA have a 30% higher chance of a good outcome at 3 months after the stroke.

What does a nurse do for a stroke patient?

Nurses working in acute stroke services have a wide-ranging role that includes assessment, identification and monitoring, as well as rehabilitation, psychological support and end of life care.

What do you do when a patient is having a stroke?

Three Things to Do When Someone Is Having a StrokeCall 911 immediately. ... Note the time you first see symptoms. ... Perform CPR, if necessary. ... Do not let that person go to sleep or talk you out of calling 911. ... Do not give them medication, food, or drinks. ... Do not drive yourself or someone else to the emergency room.More items...•

What is the nursing assessment for stroke?

The initial nursing assessment of the patient with stroke after admission to the hospital should include evaluating the patient's vital signs, particularly oxygen saturation, BP, and temperature, in addition to measuring blood glucose and performing a bedside dysphagia screen/assessment.

What happens if you have a stroke?

When someone has had an ischemic stroke (NOT a hemorrhagic stroke), a lack of blood flow caused by a blood clot (or something else) has caused some of their brain to begin to die. Unless we increase their pressure to promote collateral circulation, the surrounding area will be forever lost as well.

What is the priority for an ischemic stroke patient?

One of your main priorities with an ischemic stroke patient is their blood pressure. Typically, the physician will order their blood pressure to be higher than normal. ( Why would I ever want my new patient’s blood pressure to be 190/85!?)

What to do if sternal rub wakes you up?

If your patient needs a sternal rub to wake up and they haven’t been this sleepy, call the doctor immediately. If you think you’re not going to get worried until a pupillary or vital sign change occurs, think again. Those are LATE signs of neurological damage. So doing your neuro checks, as ordered, is essential.

What is neuro wise?

Neuro Wise - A Crash Course for New Neuro Nurses from FreshRN® is your one-stop ultimate resource and online course , crafted specifically for brand new neuro nurses. If you want to get ahead of the game so instead of merely surviving orientation, you’re thriving all the way through from day one to day done - this is the course for you.

What is the first thing to change in a neuro exam?

If something is changing in their brain, the level of consciousness/mental status is usually the first thing to change.

Can stroke patients swallow?

Make sure they’ve had a swallow/dysphagia screen before you give them oral intake. A common problem with stroke patients is swallowing. The epiglottis, which is that flap that goes over your trachea and esophagus, can be compromised. This means they can get aspiration pneumonia quite easily (“down the wrong pipe”).

What is nursing assessment?

Nursing assessments and interventions assist the team in critical decisions related to treatment efficacy and the needs of the patient.”. Throughout stroke procedures, interventional nurses anticipate patient needs, identify any potential complications and maintain patient safety.

How often should a neurologic assessment be repeated?

Current evidence also supports nurses completing a repeat neurological assessment on a patient immediately following the procedure, and to repeat the assessment every 15 minutes for the first two hours; every 30 minutes for the following six hours; and every hour for the next 16 hours.

Does a stroke have better outcomes?

Research confirms stroke patients have better outcomes and lower mortality rates when the medical facility has a specialized stroke unit. Of note, however, is that the research has not used consistent methodology and follow-up measures to assess outcomes, so more studies are needed.

What is Cerebrovascular Accident (CVA) or Stroke?

Cerebrovascular accident (CVA), also known as stroke, cerebral infarction, brain attack, is any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels of the entire cerebrovascular system. It is the sudden impairment of cerebral circulation in one or more blood vessels supplying the brain.

Nursing Care Plans

The primary nursing care plan goals for patients with stroke depend on the phase of CVA the client is in. During the acute phase of CVA, efforts should focus on survival needs and prevent further complications.

References and Sources

The following are the references and recommended sources for stroke nursing care plans and nursing diagnosis, including interesting resources to further your reading about the topic:

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Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram on difficult nursing topics. Finding help online is nearly impossible.

What to do when you call 911 for a stroke?

When you call 911 and request help, notify the operator that you suspect the person is having a stroke. Paramedics will be better prepared to help them, and the hospital can prepare for their arrival. Do keep track of symptoms. Your loved one may be unable to communicate at the hospital, so the more information you can provide, the better.

How to keep a person from being unconscious during a stroke?

To keep them comfortable, loosen restrictive clothing. Do perform CPR, if needed. Some people may become unconscious during a stroke. If this happens, check your loved one to see if they’re still breathing. If you cannot find a pulse, start performing CPR.

What happens when you have a stroke?

Do’s and Don’ts When a Loved One Is Experiencing a Stroke. Strokes can happen without warning and typically result from a blood clot in the brain. People experiencing a stroke may suddenly be unable to walk or talk. They may also seem confused and have weakness on one side of their body.

Why is it important to act fast after a stroke?

Because a stroke can be life-threatening and lead to permanent disability, it’s important to act fast. If you suspect that a loved one is having a stroke, here’s what you should and shouldn’t do during this critical time.

What conditions can you talk to a stroke patient?

These conditions might include high blood pressure, heart disease, sleep apnea, or diabetes. Do talk to the person experiencing a stroke. As you wait for the ambulance to arrive, gather as much information from the person as possible while they’re still able to communicate.

What to do if you can't find a pulse?

If you cannot find a pulse, start performing CPR. If you don’t know how to perform CPR, the 911 operator can walk you through the process until help arrives. Do stay calm. As hard as it might be, try to stay calm throughout this process.

Can you walk with a stroke?

People experiencing a stroke may suddenly be unable to walk or talk. They may also seem confused and have weakness on one side of their body. As an onlooker, this can be a frightening experience. If you don’t know much about strokes, you may not know how to respond. Because a stroke can be life-threatening and lead to permanent disability, ...

What should nurses know about strokes?

All nurses should know the warning signs of stroke, teach patients and families about these key clues, and spread the word about the importance of getting immediate help. Early assessment and rapid treatment are critical to saving brain cells—and lives.

What to do if you suspect a stroke?

Stroke or suspected stroke is an emergency that calls for an immediate response. If you suspect your patient is having a stroke, activate a stroke alert, notify the physician, or call 911 (depending on your location).

What is the National Institutes of Health Stroke Scale?

Nurses who manage patients with acute stroke should develop expertise in administering the National Institutes of Health Stroke Scale (NIHSS), a tool that objectively quantifies a patient’s stroke impairment. The NIHSS consists of 11 items that rate the patient’s neurologic functioning, including level of consciousness, best gaze, visual fields, facial palsy, motor function, limb ataxia, sensory function, language, articulation, and inattention. The lower the score, the better the patient’s prognosis. The modified NIHSS (mNIHSS), a short version of the NIHSS, is less widely used but has better inter-rater reliability than the older NIHSS.

What should be included in an initial stroke assessment?

Your initial evaluation of a patient with a suspected stroke should include airway, breathing, and circulation, followed by neurologic assessment using either the NIHSS or the mNIHSS, per facility policy. If you suspect a stroke, immediately notify the attending physician, who will call for a stroke alert or code stroke.

How long after stroke can you get a TPA?

Patients who receive tPA have a 30% higher chance of a good outcome at 3 months after the stroke. To qualify for tPA, patients must meet strict inclusion criteria; those age 18 or older with a CT-confirmed ischemic stroke may meet these criteria. However, the physician must consider many important exclusion criteria.

What is the best treatment for stroke?

For stroke patients who meet certain criteria, thrombolytic therapy to break down blood clots is the primary treatment option. Tissue plasminogen activator (tPA), the most frequently used thrombolytic, is a protein that catalyzes the conversion of plasminogen to plasmin, the major enzyme that breaks down clots.

What are the two types of strokes?

Stroke occurs in two main types—ischemic (caused by a clot) and hemorrhagic (caused by bleeding in the brain). Both types deprive brain tissue of oxygen, leading to cell death and permanent brain injury.

How to help someone who has a stroke?

Evaluate whether your loved one is having a hard time controlling emotions. Consult a healthcare provider to develop a plan of action. Stop depression before it hinders recovery. Post-stroke depression is common, with as many as 30-50 percent of stroke survivors depressed in the early or later phases of post-stroke.

What to do if you have a stroke and you are at high risk?

Survivors are at high risk of having another stroke. Make sure your loved one eats a healthy diet, exercises, takes medications as prescribed and visits their healthcare provider regularly.

How to take care of a loved one?

You have access to your loved one’s medical and rehabilitation records, including written notes and brain imaging films. Take care of you. Take a break from caregiving by asking another family member, friend or neighbor to help while you take time for yourself. Eat healthy, exercise and get adequate rest.

How long does it take to recover from a stroke?

The most rapid recovery usually occurs during the first three to four months after a stroke, but some survivors continue to recover well into the first and second year after their stroke. Some signs point to physical therapy. Caregivers should consider assistance from a physical or occupational therapist if their loved one has: dizziness;

What to do if your rehabilitation is denied?

If rehabilitation services are denied due to lack of “medical necessity,” ask your loved one’s healthcare provider to provide records to the insurance carrier and, if necessary, call the insurance company. Know your rights.

What Is Cerebrovascular Accident (CVA) Or Stroke?

Nursing Care Plans

• The primary nursing care plan goals for patients with stroke depend on the phase of CVA the client is in. During the acute phase of CVA, efforts should focus on survival needs and prevent further complications. Care revolves around efficient continuing neurologic assessment, support of respiration, continuous monitoring of vital signs, careful posi...

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Recommended Resources

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References and Sources