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Nursing Priorities

Alas, stroke patients.. my one true nursey love.

I love my stroke patients.  They have a special place in my heart.

So, you just got report from the ED and your patient who just had a large ischemic stroke is on their way up to you.  The ED nurse said their neuro exam was good so transport is bringing them up now.  (Good.. what does that mean!?)

Blood pressure monitoring is essential!

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!?)

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.  Sometimes they have to go to intensive care to get frequent neuro checks and vasoactive drips to keep it high enough to preserve that part of their brain.  We want to prevent the stroke from getting worse.

Therefore, it is essential you know your blood pressure parameters!

So, what does this mean for you, bedside floor nurse?

  1. If they have scheduled blood pressure medications (typically home meds), clarify that with the doctor.  Get some holding parameters or see if they just want to discontinue them for the time being.  Some will indicate they want “permissive hypertension” but don’t specify a limit.  Again, make sure you know your limit!
  2. Communicate with your CNA’s that we want higher pressures and to notify you if it’s too low as well as if it’s too high.
  3. Make sure you have an aspirin ordered!  You don’t want them to have another stroke!  And if they can’t swallow or you think they will not pass their dysphagia screen, ask for an aspirin suppository.
  4. Make sure they have some VTE/DVT prevention ordered.  SCD’s, subcutaneous heparin, whatever it is.. they really need some prevention!  And that can fall back on you, the wonderful nurse, if you didn’t catch that.
  5. 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”).  If their swallowing is impaired, they may be silently aspirating as well (getting food + fluids + pills into their lungs without coughing).  If there is the slightest indication they’re having problems, get a speech evaluation and make them NPO until they’re seen.  It’s a big deal.

I’ve had many patients who thought they were fine get really upset with me when I made them NPO.. then speech came around and said they were aspirating and needed a modified diet.  No matter how well you explain it, some patients will still be upset with you.  However, their safety is our priority.

Systematic and routine neuro exams

And last, but most importantly.. stay on top of your neuro exams!  Every time you go into the room is essentially a neuro check.  If something is changing in their brain, the level of consciousness/mental status is usually the first thing to change.  So if they’re suddenly really sleepy and difficult to wake up, changes could be occurring.  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.  Level of consciousness, orientation, vocal quality, ability to follow commands/response to pain, grips/drifts/dorsi + plantar flexion, and pupillary changes, are all things you’re looking at to make sure they’re still doing okay.  Do this the same way, every time.  Be systematic and routine. This is how you will detect change.

Enjoy some neuro for me!  I love it!

Disclaimer: this is informational only, always follow your hospital’s policies and procedures.