Stroke Management: Acute and Recovery Phases

Stroke Care – Acute Phase

• Frequent neurological assessments are needed using scales like NIHSSC to check LOC, motor function, and sensation changes.
• Monitor vital signs for hypertension, bradycardia, and irregular heart rhythms, controlling BP as per protocol.
• Sustain oxygen saturation above 94%, administering O2 if needed.
• Blood glucose should be closely monitored, as hypoglycemia can worsen neurological outcomes.
• Check swallowing function for dysphagia before giving oral medications or food, using a bedside swallow test.

Interventions for Stroke

• Thrombolytic therapy with tPA should be given within 3–4.5 hours of symptom onset in ischemic stroke cases.
• Administer antiplatelet or anticoagulant therapy like aspirin or heparin, based on the stroke type.
• Elevate the head of the bed to 30 degrees to lower ICP.
• Seizure precautions are needed due to the risk of post-stroke seizures.

Management (Recovery Phase)

• Mobility support promotes movement, lowers DVT risk, and reduces pressure ulcers, potentially needing walkers, canes, or wheelchairs.
• Speech therapy is given by a speech language pathologist to manage and assess communication skills.
• Occupational therapy helps patients regain daily living skills like dressing, bathing, and eating.
• Dietary modifications should be implemented with dieticians to manage nutrition based on swallowing ability, providing a heart-healthy diet with low sodium, low fat, and high fiber.
• To maintain skin integrity, turn and reposition the patient every two hours.

Discharge Teaching (Post Stroke)

• Educate patients on the need to adhere to prescribed medications, like antihypertensives, anticoagulants, and antiplatelets.
• Ensure understanding of potential side effects and when to report adverse reactions, especially bleeding with anticoagulants.

Risk Factor Modifications

• Includes stopping smoking, managing weight, controlling BP and cholesterol, managing diabetes, and following a Mediterranean or DASH diet.
• Exercise should be encouraged, gradually increasing physical activity as tolerated.

Safety Precautions

• Fall prevention involves removing tripping hazards, installing grab bars in bathrooms, and avoiding stairs without assistance.
• Advise on driving safety, typically requiring an evaluation before returning to driving.
• Assess for depression and anxiety and encourage seeking counseling or joining support groups.
• Schedule follow-up appointments with neurologists, rehab specialists, and primary care providers.

Autonomic Dysreflexia – Nursing Care

• Life-threatening condition in patients with spinal cord injury at or above T4, triggered by noxious stimuli below the injury level, such as a distended bladder, fecal impaction, or tight clothing.
• It can dangerously raise BP, increasing the risk of stroke, seizures, or death if untreated.
• Signs and symptoms include severe hypertension and bradycardia.
• Other symptoms include flushing and sweating, pale cool skin, and nasal congestion with anxiety.

Immediate Nursing Interventions for Autonomic Dysreflexia

• Elevate the head of the bed to at least 45 degrees to lower BP.
• Assess and remove the cause, such as a blocked or full catheter, fecal impaction, or tight clothing.
• Use a local anesthetic (lidocaine) before digital removal for fecal impaction.
• Loosen restrictive clothing like abdominal binders or compression stockings.
• Monitor blood pressure every 2–5 minutes until the crisis resolves.
• Give antihypertensives if BP does not decrease after removing noxious stimuli, as ordered (Nifedipine, Nitroglycerin).
• Notify the provider if any symptoms persist or if hypertension fails to resolve.

Ongoing Management of Autonomic Dysreflexia

• Educate the patient to recognize early symptoms and triggers, including bladder management with intermittent catheterization.
• Ensure regular bladder emptying, proper bowel care, and avoidance of tight clothing.
• Monitor closely if the patient has a history of autonomic dysreflexia.
• Managing bowel and bladder function should be taught for the patient's home life
• Guide the patient on how to prevent pressure ulcers and educate them about the symptoms and importance of early interventions

Interventions to Decrease Aspiration Risk

• Assess swallowing through bedside evaluations and check cough/gag reflexes to ensure effective coughing.
• Consider level of consciousness, as decreased consciousness raises aspiration risk.
• Check for slurred speech, drooling, or a wet/gurgling voice, which indicates poor swallow control.

Positioning / Dietary Modifications

• Elevate the head of the bed to at least 30-45 degrees, especially during and after meals, for 30-60 minutes.
• Use the chin tuck maneuver by tucking the chin to the chest when swallowing.
• Modified diets should be given with soft, pureed, or easy-to-chew foods based on patients’ swallowing abilities.

Feeding Techniques / Tube Feeding

• Supervise feeding, feed slowly, give one bite at a time, and give verbal cues.
• For tube feeding, elevate the head to 30-45 degrees for at least 30-60 minutes, check tube placement before and after feeds, and watch for aspiration signs.
• Administer excessive secretions or poor oral control to decrease aspiration.

Monitoring / Education

• Monitor for aspiration signs, such as coughing, choking, wet gurgling voice, SOB, or changes in oxygen saturation.
• Watch the patient's respiratory status for signs of aspiration pneumonia, like fever, increased respiratory rate, adventitious breath sounds, and decreased oxygen status
• Continuously monitor O2 saturation and provide supplemental oxygen as needed.
• Involve speech language pathologists to develop a care plan to improve swallowing, or dieticians to ensure nutrition is met.
• Educate the patient and family on swallowing techniques, aspiration signs, and proper tube feeding care.

Nursing Management of Trigeminal Neuralgia

• Assess the intensity, frequency, and triggers of pain episodes when chewing, brushing teeth, speaking, or touching the face.
• Determine the specific branches of the trigeminal nerve involved such as ophthalmic, maxillary, or mandibular.
• Evaluate the patient's ability to perform ADLs and their emotional well-being to provide social interactions.

Pain Management for Trigeminal Neuralgia

• Use anticonvulsants like carbamazepine or gabapentin as first-line treatments, and monitor for drowsiness, dizziness, or liver dysfunction.
• Muscle relaxants like baclofen help muscles relax and reduce nerve irritability.
• Consider non-opioid analgesics, as NSAIDs or acetaminophen are more effective with this condition.
• Use pain scales to assess the effectiveness of interventions, and heat or cold therapy through compresses.

Non Pharmacological Intervention

• Guided imagery or meditation promotes a relaxed state that prevents triggers from pain response.
• Educate the patient to recognize and prevent triggers such as chewing hard foods, cold air exposure, or facial movements.
• Provide a soft diet that requires minimum chewing.
• Surgical interventions include microvascular decompression (MVD), gamma knife radiosurgery, and rhizotomy. -MVD helps relieves pressure, Gamma Knife surgery is minimally invasive and Rhizotomy destroys certain fibers

Patient Education / Interventions for Complications

• Inform the patient of side effects relating to anticonvulsants while teaching them ways to avoid triggers
• Emphasize the importance of follow-up to monitor the quality of medication.
• A dietician and nutrional support is important to maintain calorie and nutrient intake
• Encourage intake of fluids and teach gentle oral hygiene techniques/ soft tooth brushes to avoid gum problems.

Early ALS Symptoms

• Muscle weakness in the hands, feet, arms, and legs, causing difficulty with tasks like buttoning clothes, turning keys, or walking.
• Muscle twitching, involuntary twitching or cramping, often seen in the arms, shoulders, tongue, or legs.
• Frequent muscle cramps, especially at night and slurred speech due to weakness in the muscles that control the mouth and throat.
• Difficulty swallowing increases the risk of aspiration, as well as increased choking and lack of fatigue.

Progressive ALS Symptoms

• Loss of motor control affects movement and can shrink muscles or damage nerve cells
• Breathing difficulties cause weakness of the respiratory muscles that lead to shortness of breath, especially during exertion or when lying down.
• Pseudobulbar affect involves uncontrollable laughter or crying unrelated to current emotions.
• Clumsiness or poor coordination causes issues with balance and fine motor skills, leading to frequent stumbling or falling.

Trigeminal Nerve / Considerations

• Facial sensation and mastication: cranial nerve 5, Sensory functions is assessed through touch
• Cranial deflections may include nerve damage and or compression
• Pt should be encouraged to follow up on regular meds in the event of unbearable pain.
• Pt can be taught gentle oral interventions to maintain dental hygiene.

Advanced ALS Symptoms

• Complete paralysis that can severely limit the ability to move limbs, speak, swallow, or breath independently.
• Respiratory failure isthe most common cause of death in ALS patients. Cognitive changes may include minor cognitive impairment

Non-Motor ALS Symptoms

• Depression and anxiety are psychological impacts that can lead to severe emotional distress
• Cognitive dysfunction involves concentration issues, decision making issues, and poor memeory
• Muscle weakness , fatigue, and increased choking can create long term issues for ALS patients.

Cranial Nerve Assessment

• The 12 cranial nerves supply motor function and sensation to the head and neck.
  • Olfactory (cranial nerve I): Smell ,Assess smell and id scents
  • Optic nerve (cranial Nerve II): Vision assess small print and have pt state when the see object/figures

Nursing Considerations - Cranial Nerve

• May relate to loss of nerves, damage, and or neurological disorders
• Deflects in sight can lead to issues like glaucome
• Oculomotor, Trochlear and Abduscens should assess for eye movement with shine Assess for smooth movement and coordinated movements.

Nuchal Rigiity / Guillain Barre

• Assess from progession ,weakness, or paralysis
• Evaluate reflexes and cranial nerves
• Assess for facial weakness and eyes
• Maintain respiratory and monitor function
• Ensure the pt is receiving enough tidal volume

Promote mobility

• Use skin care and specialized equipment
• Encourage DVT prevention and comfort

Prevent Traction

• Assess apparatus to provide full alignment and assess pain, swelling and drainage
• Clean pin sites and prevent further infection
• Help provide nutrition to promote healing and give support

Types of Fractures

1.Closed 2. Open 3. Transverse 4. Oblique 5. Spiral 6. Comminuted 7. Greenstick 8. Avulsion

Skin Integrity/ Pressure

• Monitor the area under or around the traction device for skin breakdown to prevent other infections
• Assess vitals as well to prevent infections Assess for sensation to prevent from damage and infection

Gout Pt Teaching

• Educate pts around diet, complications, and medication adherance
• Pts should maintain fluid intake and weigh/monitor trigger to prevent high uric acid levels
• Reduce the changes of kidney stones by regulating fluid intake

Range of recommendations

• Range of functions to properly increase bloodflow and use support to prevent pain and blood blockages.
• Encourage activities with a balance of proper nutrition
• Check the pt for skin issues and discomfort and offer pt resources when applicable.