nursing considerations in neurological care Flashcards
1
Q
what is pneumbra?
A
- area that could be affected by stroke
- nurses should try at all costs to save cells around primary injury
2
Q
how do nurses limit pneumbra?
A
- early stroke consultant assessment: odds of death low at 30 days
- CT scan within 24 hours
- early nurse and therapist assessment
- early swallow assessment and nutrition management
- early IV fluids and aspirin
3
Q
what are essential nursing interventions in acute stroke care?
A
- positioning: seated upright
- GCS
- BM
- BP: treat if BP >180/100
- sats <95%
- temp
- swallowing screening
- hydration and nutrition
4
Q
how do nurses prevent aspiration?
A
- positioning of head of bed (at least 30 degrees)
- suction setup
- residual neurological symptoms remain NPO until dysphagia screening
5
Q
why do nurses need to keep the blood glucose controlled?
A
- risk of diabetics
- acute hyperglycemia at time of stroke
- should monitor on admission
6
Q
why do nurses need to consider temperature?
A
- fever could have critical effect in first 24hrs after stroke
- goal - afebrile
- 37.5 - treat aggressively physical and pharmacologically
- prevent shivering