Stroke, seizure, and increased intracranial pressure nursing assessment priorities on the medical-surgical floor, distinct from the ICU neuro-monitoring deck.
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- What does the FAST acronym assess for in suspected stroke?
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Face drooping, Arm weakness, Speech difficulty, Time to call for help- What is the standard time window for giving tPA after ischemic stroke symptom onset?
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Within 3 to 4.5 hours of symptom onset- What is the priority nursing assessment for a patient with sudden neurological symptoms?
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Airway, breathing, and circulation, followed by a neurologic assessment- What causes an ischemic stroke?
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A blood clot blocking blood flow to part of the brain- What causes a hemorrhagic stroke?
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Bleeding into or around brain tissue from a ruptured blood vessel- Why must a CT scan be done before giving tPA?
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To rule out hemorrhagic stroke, since tPA can worsen bleeding- What should a nurse do before giving a stroke patient anything by mouth?
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Perform a swallow screening to check for dysphagia- What position reduces aspiration risk during a stroke patient's swallow evaluation?
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Upright sitting position (high Fowler's)- Why is blood pressure typically allowed to run higher than normal right after an acute ischemic stroke?
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To maintain cerebral perfusion to the at-risk brain tissue (permissive hypertension)- If a stroke damages the left side of the brain, which side of the body is typically weak?
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The right side of the body- What is expressive aphasia?
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Difficulty producing or forming speech despite understanding language- What is receptive aphasia?
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Difficulty understanding spoken or written language- What is the first nursing priority when a patient begins having a seizure?
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Protect the patient from injury and maintain a patent airway- During a seizure, why should a nurse never restrain a patient's movements?
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Restraining can cause fractures or other injuries- During a seizure, why should a nurse never place anything in the patient's mouth?
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It can cause airway obstruction or injury to the teeth and mouth
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