Stroke Assessment for Nurses
Empower nurses with our comprehensive Stroke Assessment guide—essential insights and tools for proactive care and optimal patient outcomes.
Fact Checked by Ericka Pingol.
What is the role of acute ischemic Stroke Assessment for Nurses?
Acute ischemic stroke assessment is an essential part of nursing care for patients with stroke. Nurses are expected to perform comprehensive and systematic physical assessments for all patients with stroke, including monitoring the main five vital signs, pain and anxiety, and levels of consciousness.
A neurological exam is performed to ascertain stroke location, establish baseline function upon hospital admission, rule out a transient ischemic attack (TIA) and other stroke mimickers, and deduce potential comorbidities.
It is composed of testing cranial nerve function, the range of motion and muscle strength, sensory integrity, vibratory sense, cerebellar function, gait, language, mental status, and level of consciousness. Baseline function is determined via the National Institutes of Health Stroke Scale (NIHSS), which focuses on the level of consciousness.
Nurses also coordinate patient assessment and collaborate care among multiple healthcare professionals, advocate for patients and their caregivers to ensure they receive appropriate care, and assist with rehabilitation and therapy.
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How do we identify and manage ischemic stroke in stroke patients?
Identifying and managing ischemic stroke in patients involves a comprehensive approach that spans from the prehospital phase to acute care in the hospital. The following steps and considerations, focusing on the provided keywords, can guide healthcare professionals in optimizing care for patients with acute ischemic strokes:
Prehospital and acute phase
- Recognition of stroke symptoms: Educate the community about common stroke symptoms and use tools such as the Cincinnati Prehospital Stroke Scale to identify potential stroke cases.
- Emergency response: Implement the "Code Stroke" protocol for suspected stroke cases and prioritize rapid transportation to a stroke unit.
- Initial assessment: Conduct a prompt neurological evaluation to identify stroke-induced deficiencies. Evaluate blood pressure and take note of any abnormalities.
- Time of onset: Gather information on stroke onset to determine eligibility for time-sensitive interventions.
- Cardiac monitoring: Monitor cardiac activity, especially for atrial fibrillation, a common risk factor for ischemic strokes.
- Blood pressure management: Maintain optimal blood pressure for acute stroke patients. Use caution with aggressive reduction in compromised cerebral perfusion.
Emergency department care
- Diagnostic workup: Perform CT or MRI brain imaging to confirm ischemic stroke and identify affected brain tissue. Assess blood glucose levels to rule out hypoglycemia.
- Thrombolytic therapy: Consider administering thrombolytic treatment, such as alteplase, within the recommended time window and perform a Rapid Arterial Occlusion Evaluation for eligible patients.
- Stroke severity assessment: Use the NIH Stroke Scale to assess stroke severity and determine if endovascular intervention is necessary for large vessel occlusion.
Nursing interventions and assessment
- Neurological assessment: It's important to regularly evaluate motor function, swallowing ability, and other neurological symptoms and watch for signs of secondary brain injury.
- Peripheral vascular disease and deep vein thrombosis: Assessing for peripheral vascular disease and deep vein thrombosis in stroke survivors is essential. Early ambulation and anticoagulant therapy should be implemented as preventive measures when appropriate.
- Post-stroke care: Implement nursing interventions for stroke survivors, including rehab, lifestyle changes, addressing post-stroke complications, and providing ongoing education.
- Stroke risk factors: Identify and manage modifiable risk factors, such as hypertension, diabetes, and atrial fibrillation.
- Specialized stroke unit: Transfer patients to a specialized stroke unit for dedicated care.
- Follow-up and recurrent strokes: Establish a follow-up plan to monitor for recurrent strokes and adjust management accordingly.
What is the health stroke scale and its application in acute stroke care?
The National Institutes of Health Stroke Scale (NIHSS) is a systematic and quantitative assessment tool for measuring stroke-related neurological deficits. It is designed to objectively quantify the impairment caused by a stroke and aid in planning post-acute care disposition.
The scale is composed of 15 items that evaluate the patient's level of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. A trained observer administers the scale, and scores range from 0 to 42, with higher scores indicating greater stroke severity.
The NIHSS is used to assess and document neurological status in acute stroke patients, determine appropriate treatment, and assist in standardizing communication between healthcare professionals. It is a predictor of both short and long-term outcomes of stroke patients.
Health professionals, including nurses, use the NIH Stroke Scale to measure neurological function and deficits by asking the person to answer questions and perform several tasks. The scale is also used in stroke education for healthcare professionals, and training courses often include the NIHSS assessment.
Why is cardiovascular and stroke nursing crucial for acute stroke patients?
Cardiovascular and stroke nursing is crucial for acute stroke patients because it involves a comprehensive approach to care that addresses the complex needs of stroke patients. Nurses play a vital role in identifying patients at risk of clinical deterioration by undertaking ongoing observation and assessments, including neurological, cardiovascular, respiratory, and musculoskeletal examinations.
They also assist with administering thrombolytic therapy, monitoring vital signs, and managing potential complications such as aspiration, pneumonia, and deep vein thrombosis. Nurses also coordinate care with other healthcare professionals, including physicians, therapists, and social workers, to ensure that patients receive comprehensive care that addresses their physical, emotional, and social needs.
In addition to providing personalized care, nursing care plans also involve educating and supporting patients and their families. This includes providing information on stroke prevention, rehabilitation, and community resources to ensure a comprehensive approach to care.
How do nurses assess blood flow and vital signs in stroke patients?
Nurses assess blood flow and vital signs in stroke patients through a comprehensive evaluation of the patient's neurological, cardiovascular, respiratory, and musculoskeletal systems. They monitor the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, to detect any changes that may indicate clinical deterioration.
Nurses also assess the patient's level of consciousness, motor and sensory deficits, and neurological function using the National Institutes of Health Stroke Scale (NIHSS). They also evaluate the patient's risk factors for stroke, such as hypertension, diabetes, and hyperlipidemia, to guide treatment decisions.
Nurses may also assist with administering thrombolytic therapy, monitor for potential complications, and coordinate care with other healthcare professionals to ensure that patients receive comprehensive care that addresses their physical, emotional, and social needs.
What are modifiable risk factors in stroke care and prevention?
Modifiable risk factors in stroke care and prevention include hypertension, diabetes, hyperlipidemia, smoking, physical inactivity, obesity, and excessive alcohol consumption. These risk factors can be managed through lifestyle modifications, such as regular exercise, healthy diet, smoking cessation, and limiting alcohol intake.
Medications, such as antihypertensives, antidiabetic agents, and statins, can also manage these risk factors. Nurses play a crucial role in identifying and managing modifiable risk factors in stroke patients through ongoing assessments, patient education, and collaboration with other healthcare professionals.
How can nurses recognize and address hemorrhagic stroke in patients?
Nurses play a crucial role in recognizing and addressing hemorrhagic stroke in patients. They are responsible for conducting ongoing assessments, including neurological evaluations and vital sign monitoring, to detect changes that may indicate a hemorrhagic stroke.
Additionally, nurses assist in administering time-sensitive treatments, such as monitoring and managing potential complications, and coordinating care with other healthcare professionals to ensure that patients receive comprehensive care.
What nursing strategies improve patient outcomes in the acute phase of stroke?
Nursing strategies that improve patient outcomes in the acute phase of stroke include:
- Assessment and monitoring: Nurses conduct comprehensive assessments, including neurological, cardiovascular, respiratory, and musculoskeletal evaluations, to detect changes that may indicate stroke or its progression.
- Education and support: Nurses provide patient and family education on stroke prevention, rehabilitation, and community resources, empowering them to manage their health and reduce the risk of recurrent strokes.
- Coordination of care: Nurses collaborate with other healthcare professionals, such as physicians, therapists, and social workers, to ensure comprehensive care that addresses patients' physical, emotional, and social needs.
- Rehabilitation and therapy: Nurses assist with rehabilitation and treatment, including physical and occupational therapy, to help patients regain motor function, balance, and independence.
- Managing risk factors: Nurses monitor and address modifiable risk factors for stroke, such as hypertension, diabetes, and hyperlipidemia, to reduce the likelihood of complications and improve patient outcomes.
- Prevention of complications: Nurses take preventive measures to minimize complications, such as pressure ulcers, contractures, and deep vein thrombosis, by proper positioning and care of patients.
- Patient and family teaching: Nurses educate patients and their families about stroke risk factors, prevention strategies, and available treatments, as well as the importance of timely intervention and rehabilitation.
- Health promotion: Nurses encourage healthy lifestyle habits, such as regular exercise, healthy diet, smoking cessation, and limiting alcohol intake, to reduce the risk of stroke and improve patient outcomes.
Why is early neurological deterioration critical in stroke care?
Early neurological deterioration in stroke care is critical for several reasons:
- Time-sensitive treatment: Timely intervention is crucial for acute ischemic stroke, as every minute counts in saving brain tissue and minimizing the risk of long-term complications. Early initiation of treatment, such as thrombolytic therapy or mechanical thrombectomy, can significantly improve patient outcomes.
- Prevention of secondary complications: Early neurological deterioration can lead to secondary complications, such as seizures, hemorrhagic transformation, or ischemic stroke in other brain regions. Nurses must closely monitor patients for signs of complications and initiate appropriate interventions to prevent long-term damage.
- Optimal brain recovery: Early neurological assessment and monitoring are essential for identifying areas of brain dysfunction and guiding appropriate interventions. Nurses are crucial in conducting regular neurological evaluations, such as the National Institutes of Health Stroke Scale (NIHSS), to track patient progress and adjust treatment plans accordingly.
- Rehabilitation and support: Early identification of neurological deterioration allows timely referral to rehabilitation services, such as physical and occupational therapy, to help patients regain motor function, balance, and independence.
- Patient education and family support: Early neurological deterioration can be a stressful and confusing experience for patients and their families. Nurses provide emotional support and instruction on stroke risk factors, prevention strategies, and warning signs of recurrent stroke to help patients and their families better understand and manage their condition.
- Quality of life: Early neurological deterioration can significantly impact a patient's quality of life, independence, and ability to participate in daily activities. Prompt diagnosis and treatment can help minimize the long-term effects of stroke on a patient's physical, emotional, and social well-being.
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Commonly asked questions
Patients suspected of having an acute stroke should undergo an assessment that includes measuring their heart rate, blood pressure, body temperature, oxygen saturation, and glucose level and checking for seizure activity.
The two main types of scans used to assess the brain after a suspected stroke are CT and MRI scans.
What is the assessment after a stroke?
The NIHSS is a tool used to assess neurological status after a stroke. It includes 11 items, such as level of consciousness, facial palsy, and neglect of visual, sensory, motor, language, or speech deficits. The items are answered using a 3 or 4-point ordinal scale.
If stroke is suspected, a timely and focused clinical assessment in primary care is necessary to avoid delays in admission and treatment. Obtain a focused history from the patient and, if possible, a collateral history from family members or witnesses.
